Bariatric surgery is the most successful intervention for weight loss in patients with obesity, but patients can lessen its benefits by continuing unhealthy behaviors. To achieve the best long-term results, patients are encouraged to adjust their lifestyles and make lifelong changes, which can require altering long-held thoughts, attitudes, and beliefs.

The lifestyle component is so critical that patients may benefit greatly from working with a behavioral health provider who specializes in bariatric surgery, according to clinical psychologist Kelli Friedman, PhD, of the Duke Center for Metabolic and Weight Loss Surgery.

“By the time patients reach the point when they are considering surgery, they typically have a long history of weight-loss attempts, with limited long-term success,” Friedman says. Given their history, they often have a lot of knowledge about recommendations for weight loss. So the question becomes how to bridge the gap between knowing what to do and knowing how to integrate some of these behaviors into their lives. A psychologist who can apply the techniques of cognitive behavioral therapy (CBT) can boost patients’ chances of long-term success—which is why Duke’s interdisciplinary bariatric surgery team includes psychologists with specialized training in working with bariatric surgery patients.

“As psychologists, we help identify barriers, come up with strategies, problem solve, and assist our patients in figuring out how they are going to implement some of the needed changes given their individual life circumstances,” Friedman says.

For example, when post-bariatric surgery patients report difficulty with increasing their physical activity, a psychologist can assist in identifying thoughts that may interfere with their motivation to exercise. Patients may say to themselves, “Unless I exercise for an hour per day, there is no point in exercising at all.” A CBT therapist can identify this thought as an example of “all-or-none thinking” that can lead to negative outcomes, and discuss whether exercising for 10 minutes might actually have benefits—and if it would be easier to get motivated for shorter amounts of physical activity.

By helping patients understand the role of their thoughts in influencing their behavior and learn how to restructure unhelpful or inaccurate thoughts, CBT can help patients improve their ability to change their behavior, says Friedman, who contributed a section with psychological insights to a 2017 American Gastroenterology Association white paper on obesity care.

Similarly, some patients may have foregone gym visits because they have difficulty prioritizing their own needs over the needs of others. “We try to help patients set clear boundaries, to say, ‘this is important for my health.’ We try to reinforce their positive changes, figure out ways to prioritize their own needs, and encourage them not to apologize or feel guilty for putting their own health- and self-care first,” Friedman says.

Support groups are commonly offered for bariatric surgery patients, but Friedman notes that the  CBT groups Duke offers can be an important supplement to the general support groups. “Cognitive behavioral groups tend to be smaller than support groups, typically about eight patients. These groups are more intimate and focused. We focus on how our thoughts and behaviors impact not only outcomes but also emotions, which then in turn can impact our behaviors,” Friedman says.

For example, some patients may need to reframe their thinking about socializing and food. “Some people might focus on how sad it is that they can’t eat Aunt Emma’s pecan pie anymore at a family celebration,” Friedman says. “We try to shift the focus from food to family and friends, and have patients think a little differently than they did before about eating, emotions, socializing, and exercising.  One of our main goals is to help our patients maintain healthy behaviors in order to assist with optimizing their long-term success with surgery.”   

“Very few psychologists specialize in working exclusively with bariatric surgery patients, and we are fortunate at Duke to have several psychologists who are a part of our program,” Friedman concludes. “Specialized training allows one to employ a well-validated type of psychology that is really useful for weight loss.”