Tuesday, June 12, 2012

Pre-Surgical Assessment Disparities

It has come to my attention that there is a HUGE disparity in the pre-surgical psychological assessment requirements. I have heard stories of surgeons not requiring it at all, mostly in the case of self pay patients. I can't argue this one, as I was self pay and all my surgeon asked was that I write out my case history to represent all my attempts in the past at dieting and my therapeutic intervention history. However, in the event that an insurance company requires psychological assessment, there seems to be no formal, professionally accepted standard of assessment. Some patients report having to fill out a brief questionnaire, while others report 2-3 hours of personality assessment and interview with a psychologist.

Why is this harmful to the future outcomes of bariatric surgery patients?  Glad you asked.  There are certain indicators that may show a patient is susceptible to regain.  Past dieting history is the number one most important factor indicating success - if a person has not shown they can stick to a strict diet for at least 30 days at a time, that's a red flag no clinician should be willing to ignore. However, when you don't thoroughly assess for Axis II (better known as personality disorders) you discount the potential for deceptive factors of a client's character.

I know, I know... people don't lie to their therapists. Yes, sure they don't. Everyone wants the help of a trained therapist and everyone is willing to cooperate.  I know this to be a fallacy. Every day, I can tell you that my clients try to pull a fast one on me, they aren't committed to therapy for one reason or another because telling the truth makes them vulnerable.  In the instance of pre-qualification for surgery, patients are more worried about not being approved and they will hide what they think *might* disqualify them.

Honestly, the only thing that I've ever heard a clinician say would disqualify someone for surgery was a psychotic disorder, where the patient was unable to make good judgments on their own and could not be trusted to follow the post-op requirements due to their lack of mental capacity. All other instances have resulted in the clinician recommending a certain amount of counseling prior to surgery. Some clients will comply with this gladly, others will resist and even choose not to have surgery to avoid having to talk about the underlying problems contributing to their weight gain.

All I can say about the latter is that the person is doing a disservice to themselves by not taking the recommendation to seek more therapy prior to surgery. The weight loss journey after surgery is a totally different experience than just plain dieting and sticking to a diet. The weight loss journey after surgery is not an option. It's necessary, it's not a choice, it's a way of life. It is what it is, you have to commit to taking care of yourself all the time, not just when you feel like doing the right thing. The result of failure to follow doctor's orders puts a patient at risk... of death.  I am not trying to be the whistle blowing alarmist, but there is still risk involved when you have invasive surgery to change your stomach, guts and intestines.

Of course you can choose to do what you know what you're not suppose to do. We all have "free will." However, in the long run, it will catch up to you. We can't hide from our problems forever. They will manifest in some way, shape or form in areas of life that may be unrelated to affected area.

So, what do I propose?  I propose standardization of the basic psychological assessment process. There are a few very good tools that can be administered in a 2-3 hour time frame, including time for clinical interview and assessment feedback. The Beck Depression Inventory, The MMPI (Minnesota Multiphasic Personality Inventory), the EAT-26, which is available online and more focused on the Anorexia and Bulimia perspective but still provides a thorough assessment and is clinically useful, as well as the ACORN assessment. While this is just a baseline of what should be examined, it is my belief that these tools, intake interview, and intervention should all be utilized before going under the knife.

I welcome your thoughts and experience on this matter... 


  1. Nanette,

    My name is David Mahony and I am a Clinical Psychologist. I have been working with bariatric surgery patients for the past twelve years conducting pre surgical evaluations, pre and post surgical treatments, and I have published research on the subject.

    I commend your attempt to "standardize" the pre surgical clearance process. It is something that I've been trying to do for the past ten years! I think you have identified some of the main problems in this area.

    One of the biggest problems when discussing the standardization of the pre surgical evaluations is that we do not have a thorough, long-term, knowledge base that outlines all of the possible post surgical psychosocial problems. We have research reports of post surgical problems including some patients committing suicide, some developing problems with drugs and/or alcohol, some regaining the weight that they lost, and anecdotal reports of post surgical anorexia and bulimia. In spite of this, we do not have a thorough, empirically based understanding of all of the possible post surgical psychosocial problems. Additionally, even for the problems that we are aware of, we do not have much empirical data on pre surgical markers or red flags. Which patients will commit suicide? Which will regain all of their weight?

    Until we have identified all possible post surgical problems and good pre surgical markers, we will be limited to using our clinical judgment or simple hunches.

    This process is further complicated by patients' unwillingness to be open and honest during the psychological evaluation. Patients are often not aware of their problems or they do not feel that the problems that the have are connected with the surgical weight loss process so they do not report them. Bariatric candidates are particularly difficult in this manner because they will often "fake good" when they are afraid they will not receive psychological clearance. Obesity and problematic eating behaviors are not things that patients talk about openly due to the stigma and humiliation that they have experienced in the past.

    Part 1 0f 2

  2. Part 2 of 2

    When I began evaluating patients for bariatric surgery I used a wide range of commercially available tests, including the MMPI and MBMD. I was frustrated by the results that I received since these tests were not designed for bariatric evaluations and did not answer the referral questions that needed to be addressed. Furthermore, patients were often irritated after spending hours completing these tests. They did not feel that the tests had any connection to their efforts at weight loss or bariatric surgery and they complained about the lengths of the tests.

    In an effort to address these problems, I developed a test called the PsyBari. The PsyBari is a psychological test that was designed specifically for bariatric surgery candidates. It attempts to assess all known and hypothesized post surgical psychosocial problems.

    Additionally, it was designed to be scored on line so that it could address the limitations in our knowledge of post surgical problems. It does this by being easily upgraded as the research community discovers and publishes new findings on post surgical psychosocial problems.

    The PsyBari can be completed in approximately 30 minutes so instead of leaving patients irritated they are often “warmed up” and eager to discuss obesity related matters.

    I’ll give you a quick summary of some of the features that the PsyBari includes that were designed specifically for bariatric candidates. As we know, when completing psychological evaluations bariatric patients are now always honest and open. To address this, the PsyBari has three validation scales that assess response biases that are specific to bariatric candidates including minimization, denial of obesity related eating habits, and attempt to “fake good” so the they will pass the psychological evaluation. These validation scales take the guess work out of trying to determine how honest a patient was during an evaluation. The clinician can now interpret the rest of the results with confidence.

    Additional features include using test items that bariatric patients are receptive too. For example, if you ask a bariatric patient if they are depressed, they will almost always adamantly say no. They do not want to be seen as having psychological problems and they are afraid they will not pass the evaluation if they admit to psychological problems. In contrast, if you ask them if they are depressed about their weight, they will eagerly acknowledge symptoms of depression since they feel the question accurately captures their condition without making them feel that they have a more global problem.

    These are some of the features that are included in the test but there is much more. I would like to know your thoughts about the PsyBari and can send you some information on the test if you are interested.

    David (DrDavidMahony@Gmail.Com)

    1. There are a variety of new assessments out there to address these issues, and I would like to see yours. If you could email me information on the test, I'd be happy to take to a look at it and see if it's something I could use with my clients. (nanette at bariatriccounselor dot com)

  3. Thank you for articulating some of the issues with pre-operative psychological evaluations for bariatric surgery. While most surgeons do require that people have psychological "clearance" for surgery, there is very little consensus amongst mental health professionals in terms of what this evaluation entails and even who is qualified to do the evaluation. Some of the mental health professionals conducting evaluations have little knowledge of bariatric surgery including what are the contraindications for surgery. There is value in having the pre-operative evaluation done by a professional with knowledge about this specific type of evaluation and the types of issues that people tend to struggle with post-op. In addition to the standardization that you mention in terms of the test battery, I think that there should also be some standardization in terms of the qualifications for who can perform these assessments- at least in areas where specialists are readily available. Thanks for opening this conversation.
    Alexis Conason, Psy.D.
    Licensed Clinical Psychologist

    1. There are certainly important factors to take into consideration when doing pre-surgical assessments. I have seen first hand, clients struggle post-op because adequate preparation was not taken or pre-existing psychological issues were not appropriately addressed. It just seems, at minimum, intake, standard psych eval, and some counseling and psycho-education would benefit. Glad you found my blog, and I'll check out your site.