A familiar client population has a new need. Obese clients are coming in droves to MFT offices in order to prepare for or discuss the change of their lives. These clients want to lose weight and they want to lose it so badly that many are willing to look you, as a therapist, in the eye and say, "Yes, I clearly understand that a complication to gastric bypass surgery may be my death, but I can't keep living like this anymore-so it's a risk I'm willing to take."

Gastric bypass surgery or bariatric surgery has been on the rise in the last decade. It is estimated that 130,000 more clients will
undergo surgery this year compared to ten years ago.1 This surgery, which can reduce a patient's stomach to a small pouch, is often approved and is offered by a growing number of surgeons as a way to lose enormous amounts of life threatening weight. It is a miracle tool for numerous clients that require a life-altering commitment, both prior to the procedure and after the surgery. Clinicians will be challenged to learn more about the surgery and the long-term effects on the clients' psyche, since this surgery
affects not only the body, but the clients' personal and interpersonal thoughts and actions.

A person is determined to be obese if he/she has met certain criteria. This criteria, as currently established by the National Institute of Health, includes, on average, that the patients are: between the ages of 21-60, although older and younger clients may be accepted at specific operating facilities, at least 100 pounds over their ideal body weight, have a Body Mass Index (BMI) score of 40-55 or BMI of 35-40 with serious co-morbidities, have a history of weight-loss attempts, have a willingness to participate in a multidisciplinary program, and are at an acceptable risk level for surgery.2

Obesity to this extent generally has led clients towards hosting co-morbidities, which can include hypertension, sleep apnea, joint pain, diabetes, depression, coronary artery disease, elevated cholesterol, gallstones, increased risk for cancer, and premature death.3 Weight reduction can alleviate or eliminate several of these co-morbidities that limit so many daily activities.

Two surgery options are the Roux-en-Y Gastric Bypass and the Vertical Banded Gastroplasty also known as the Lap-Band. Each surgery has its own similar sets of complications with the latter being the less invasive surgery of the two. The Roux-en-Y reorganizes the internal organs through the creation of a smaller stomach pouch that is then joined to the small intestine. Food will pass directly from the small pouch into the intestine.4

The role of the therapist is critical and treatment depend on the type of surgery that best suits the client as well as the stage at which the client seeks treatment. The therapist may be meet with a client in one of five stages. The stages are Questioning, Evaluation, Surgery, Post-Surgery and Long Term Post-Surgery. In the Questioning stage, clients may have heard about Weight Loss Surgery (WLS) from sources such as a family member, doctor, co-worker, or a newscast. Often, the clients are uncertain about what is involved in the process. These patients have tried to lose weight through various forms and think that surgery is the next logical step. They want information about statistics, physicians, the process, nonsurgical treatment options, and the longterm requirements of both types of surgery. As a therapist to a client in this stage, you are a resource . You can suggest books, websites, or support groups, so that clients can become more educated about what the process involves.

During the Evaluation stage, the therapist may be utilized by physicians, insurance companies, or patients to evaluate the client's mental status, readiness for surgery, and ability to follow-through for life with the required post operative regime. At this stage, a client will attend a session with a nutritionist and will complete medical tests to establish compatibility for surgery. Emotions can fluctuate for these clients, because they have to face their past and present eating patterns. A client may have been over-weight for his/her entire life or he/she may have gained weight because of critical life moments such as abuse, work-related accidents, or the births of children. While having thoughts about how clients become the weight they are, clients may be faced with finding out that they have co-morbidities that they never knew they had. Finding positive confirmation regarding diabetes or sleep apnea can be both relieving as well as devastating, depending upon the treatment that the client may have to begin regardless of surgery. The therapist supports the client with any feelings of loss that he/she has regarding newly diagnosed medical conditions. The therapist helps the clients to talk about fears about living and dying during this time. Most importantly, the therapist may find that the client exhibits signs of eating disorders, low self-esteem, depression, or attention deficit. It is imperative that the client seek consultation prior to surgury with a psychiatrist, in order to discuss any necessary medical treatment for mental illness. The therapist is also available to the client, should he/she not be approved for surgery, because of certain conditions or the current inability to follow-through with life altering eating habits. Counseling can be required or recommended so that clients go into surgery both physically and mentally prepared.

The Surgery stage triggers needed planning and feelings of readiness and doubt. The planning questions you might ask a client include, "Who will drive you to and from the hospital? Have you bought the foods and supplements you will need following surgery? Who have you told about the surgery and do you think this will change your relationship with them?" Clients can forth create of other surgeries they have had or fears regarding not waking up from surgery. Anxiety management techniques, that may include a practice visit to the hospital are helpful during this stage. The goal is for the client to have all of his/her questions about the surgery answered and to be at peace with his/her decision to continue. The client needs to be clear about the risks and his/her own expectations of what the surgery can offer.

Post-Surgery can go smoothly and clients may be walking around within two days or there can be complications associated with surgery, such as infections. Malnutrition and dehydration are important concerns to keep in check by following the diet and consulting with a nutritionist and physician. Emotional eating can also surface within the first month or so post-surgery, as clients realize that all of their planning and their surgery checklist are completed. This can be a disappointing phase with questions like, "Now what?" The therapist can work with clients on issues involving partners and other relationships. Sometimes helpful friends can make the clients feel awkward. One client shared that a co-worker brought over chicken soup. It was a wonderful gesture, but half of the soup was vegetables that the client couldn't eat. Should the client educate the co-worker about the new diet or should he/she simply say thank-you and give the soup to someone else? Clients face comments like, "Wow-you look so much better!," Or "Are you okay you seem to be losing a lot of weight?" How much information should be shared and with whom, may difficult decisions for clients. The therapist can help the client work through issues may never have been anticipated.

The last stage is Long-Term, Post-Surgery. The clients are losing weight and are either becoming more active and excited, or more scared and depressed. Some are glad the medical conditions are changing, while others face the fact that certain conditions will not go away. Long-Term weight reduction is similar to time travel for clients, because while they lose the weight, they gain wrinkles and look older, yet their minds remind them of the last times they were lower in weight, which often, is twenty or thirty years prior. It can be disorienting for clients. Therapy is a very useful place to work on these discrepancies. Therapists are also valuable in working through relational issues that arise, especially near the holidays. Just because the client has changed, does not mean that everyone in his/her life is supportive. Clients may feel degraded by others for "taking the easy way out." Surgery is not easy, nor are the resulting lifestyle changes, but it is worthwhile for many clients. When completed, clients can gain:the ability to exercise; the strength to run after children or grandchildren; the size to fit into seats and buy clothes from stores in the mall; and have a longer, more healthy life. It is not the only answer to weight loss, but it is a powerful medical tool that thankfully is available to save the lives of so many obese clients. MFTs should be ready to educate, challenge, and figuratively hold hands with clients through the ordeal.

REFERENCES

1. Newman, C. (2004, August). Why are we so fat? National Geographic, 206, 46-61
   
2. Spotlight Health. (2001, November). Retrieved August 17, 2004 from http://www.spotlighthealth.com/morbid_obesity/ weight_loss_surgery/candidate.html
   
3. Stiles, S. (2003, Spring). Severe Obesity, Permanente Journal, 7, 49-52.
   
4. ThinnerFuture. (2003). What is bariatric surgery? Retrieved August 17, 2004 from http://www.thinnerfuture.com/prog_overview/BS.htm