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...