Body Transformation or Body Dysmorphia?

It’s easy to get caught up in the perfectionism psyche when things are changing so quickly after bariatric surgery. You imagined yourself thin, fit and svelte, but really, you did not comprehend what it would be like to have hanging flesh on your body after you worked so hard for that body. Have you caught yourself thinking, “I just don’t like the way I look in the mirror,” while naked.  Today’s blog is about how to have a healthy mentality about your body after weight loss surgery, considerations for a reasonable time frame to pursue plastic surgery, recognizing unreasonable body image issues, understanding self harm, and working through those issues with a therapist, and stopping unproductive negative self talk.

In the case of the bariatric surgery patient, self acceptance has its limitations, but we must live with the understanding that a model perfect body isn’t going to happen. Where does the line get drawn in the sand between trying to achieve a figure that you can be happy with and living with an obsession with the knife?  It’s certainly possible for anyone to become addicted to ANYTHING. However, in the bariatric transformation from obese to healthy, thin, or slim, if money is no object: is there a such thing as an addiction to plastic surgery?  Better yet, is there room for concern about those members of the community who begin the journey of going under the knife?  Should professional psychologist and mental health professionals look at case history in order to determine if that person will be stable enough to withstand the psychological impacts of plastic surgery, or will it become obsessive?

There’s no way to screen for risk in this regard.  However, the question has been posed that maybe those with personality disorders with a history of cutting might take this journey to extremes.  Like I said, anything is possible with anyone, at any point in time.  Having unlimited resources to indulge in plastics, self harm in pursuit of perfection is certainly obvious with many mega-stars.  Michael Jackson certainly too it to an extreme if you think in terms of his numerous plastic surgeries and history of mental and psychological abuse, albeit extraordinarily talents, he brought it to the max.

Influenced by media, society’s expectations of a perfect body are skewed. We have to love ourselves, and under no uncertain terms should be not love our body, imperfections and all. An otherwise successful, yet dissatisfied bariatric patient’s excess skin removal, coupled with destructive behavior patterns are indicative of a more severe diagnosis of body dysmorphic disorder diagnosis, or even, pronounces issues of self harm included, going under the knife that could be indicative of a borderline personality disorder. How do can we tell the difference?

To identify behaviors as unhealthy and unproductive as a chronic mental illness, one must look at the client’s ability to control the obsessive negative thoughts, (i.e. you can't stop thinking about a flaw in your appearance — a flaw that is either minor or imagined) when your appearance seems so shameful that you don't want to be seen by anyone.  Body dysmorphic disorder is intensely obsessive, image and appearance are often thought about for many hours a day. The perception of your flaws causes you significant distress and has an impact on your ability to function in your daily life. If one seeks out numerous cosmetic procedures or excessively exercise to try to "fix" the perceived flaw but is never satisfied.

The three essential factors I would use to determine an unhealthy obsession with appearance (occupies more than 90 minutes a day, of persistent negative thoughts about self) body image issues, overanalyzes the perception of others on the individual (implied or stated), personality disorder, and GAF (Global Assessment of Functioning) Score.  Any client with a score below 65 on the scale would be of concern to me, as a clinician.

So, how do we define an unhealthy obsession with your body, perfectionism and surgical methods to alter one’s appearance?  Where do self harm/self injury, perfectionism, and personality disorder come into play here?  There’s a certain level of desperation that is a driving motivator to change, but when does it become a disorder?  That’s subjective.  However, there are some issues to consider when moving forward to the transformative body reconstructive surgeries.  A healthy cognition about when that should be done is essential. 

In my former journey with the Lapband, my mother pestered about my bat wings. I always said, “Let me get to my maintenance weight for two years, and then we’ll talk plastics.” Good thing I never got to that point, else when the band came out I and the slow path of my body fighting back with regain set in, I would have been a helluva messy rubber-banded skin.  If nothing, I am logical, methodical and grounded in my decision making—after 6 months, I knew that the Lapband had been a HUGE mistake. (That’s another post, I have been meaning to write out my Lapband trauma during hurricane Isaac for 10 months now, I owe the public that story. I want to tell it.  It’s just tough to tell it through the therapeutic lens while I’m still working out the details on revision, and I still don’t know when that can or will happen.)

My intentions with blog are to discuss the perfecta of concerns I have for the WLS community.  All of us are crazy, varying degrees of crazy, yes, but some have had more severe mental illness histories than others.  Analysis of previous history of self harm should not preclude patient disqualification, however certain support services should be available to those patients who find themselves forming harmful habits and/or destructive thinking patterns as the transformation of an obese body becomes slimmer.

Signs are inclusive but not limited to negative feelings or thoughts, depression, anxiety, tension, anger, generalized distress, self criticism, self injury, low mood, poor self confidence, preoccupation with dangerous behaviors, purposefully engaging in harmful acts, urges that cannot be distracted from or satisfied, negative/harm act results in pleasure, spending endless time alone in a room avoiding others, and/or 

disruptive influence on interpersonal, academic or other areas of life functioning. 

If you find yourself constantly thinking about these issues, you have options and alternatives.  While I it is important to work with a trained professional, keep in mind that developing hobbies and interesting that help to take the focus off of your dissatisfaction help to low your risk:

• Paint, draw, or scribble on a big piece of paper with red ink or paint
• Express your feelings in a journal
• Compose a poem or song to say what you feel
• Write down any negative feelings and then rip the paper up
• Listen to music that expresses what you’re feeling
• If you cut to calm and soothe yourself
• Take a bath or hot shower
• Pet or cuddle with a dog or cat
• Wrap yourself in a warm blanket
• Massage your neck, hands, and feet
• Listen to calming music
• Call a friend (you don’t have to talk about self-harm)
• Take a cold shower
• Hold an ice cube in the crook of your arm or leg
• Chew something with a very strong taste, like chili peppers, peppermint, or a grapefruit peel.
• Go online to a self-help website, chat room, or message board
• Exercise vigorously—run, dance, jump rope, or hit a punching bag
• Punch a cushion or mattress or scream into your pillow
• Squeeze a stress ball or squish Play-Doh or clay
• Rip something up (sheets of paper, a magazine)
• Make some noise (play an instrument, bang on pots and pans)
• Substitutes for the cutting sensation
• Use a red felt tip pen to mark where you might usually cut
• Rub ice across your skin where you might usually cut
• Put rubber bands on wrists, arms, or legs and snap them instead of cutting or hitting

Source: The Mental Health Foundation, UK

Professional treatment for cutting and self-harm

If your concern is for a loved one because you’ve noticed suspicious injuries or that person has confided to you that he or she is cutting, pulling, scraping or harming themselves in this way, whatever the case maybe, intervention is essential.  Speak respectfully, without blame, and in a calm tone.  Address the matter with an open mind and loving heart.  You are extending a hand to someone who is hurting on the inside.

Deal with your own feelings on the matter prior to the discussion, the shocked, confused, or even disgusted by self-harming behaviors—and guilty for your loved one’s distress can be helped by acknowledging how you feel about this person’s emotional distress. Make the first step by learning about the problem and overcome any discomfort by understanding why your friend or family member is self-injuring. This will help you to see the world from his or her eyes. Avoid judgment and criticisms it is likely the route of the problem, the person is coping with society’s judgment and expectations.  Find your loved one support and make your conversation productive.  Availability to listen and find help is a key to recovery.  Communicate with them as they seek support and intervention.  Above all, be kind to yourself and others when you speak about sensitive subjects. 

New Series on Understand Counseling Theories: Part One - Understanding Theoretical Orientation

We are all unique individuals with certain needs in therapy. I hear very often people say, "I only went to therapy a few times, I didn't like my therapist."  This concerns me because not all therapists are meant for every client. Taking the time to interview your therapist about their approach to counseling is advisable. Any good therapist will give you some time on the phone to discuss their theoretical framework and approach to your specific concerns and issues.

Each therapist is going to have their unique theoretical orientation. This simply means they follow certain schools of thought in the way they interact with clients. What this means is that counselor uses certain techniques to engage clients in meaning for processing of their issues. In this series, I will do my best to explain what a therapist's theoretical orientation is and how you can choose a good fit for your reason for therapy.

There are several central figures in the history of psychology. Sigmund Freud is quite possibly the most renown psychotherapist and the "Father of Psychotherapy." As the field of psychology grew, so did the theories of great thinkers and researchers alike. Freud's psychoanalytical theory provides a set of terms, guidelines, therapy techniques, ways of thinking etc. The picture comes to mind of a person on a couch exploring their experience through talk therapy. Consideration to what you seek therapy for may often dictate which orientations suit your needs. If you like the "talk it out" process and believe that a listening ear and thoughtful insight are good counseling, a psychoanalysis may be the way to go. However, most therapists' are going to use talk therapy and psychoanalysis to an extent, and their actual theoretical orientation is something they call "eclectic," which maybe a combination of many schools of thought.

Often times, our issues maybe central to the relationships in our lives.  Our family structure or relationships may post strains on our ability to cope with difficult problems or emotions. If you are seeking counseling for your marriage and family issues, a marriage and family therapist would engage you in the Family systems theory and process your issues with you through this theoretical framework. A session would look very different than an individual counseling session where the therapist practice existential counseling theories (but more on that later.)  Family systems theories are often performed as an ancillary function of their role as a leader in the community, such a priest or reverend, chief of a tribe or head of a spiritual group.  This approach can be useful with interventions for drug and alcohol abuse if the person holds those in high regard and it fits within that person's belief system. Generally, this spiritual framework will only work if the person accepts the intervention and is willing to do the work to repair broken relationships.

Generally, counselors employ the techniques of more than one theoretical framework.  You will often her them say they are "existential therapists" which means that person employs the use of more than one theoretical approach.  A counselor can practice more than one type of therapeutic intervention and even take into consideration the beliefs of their client in order to meet their needs. An individualistic approach tailored to that client's needs is the best approach by any counselor. However, some therapists choose to work within their framework and don't adapt to client's needs. A counselor who offers you a person centered cognitive behavioral therapy combination may favor may be guided by the behavioralist in their interventions but uses a person centered approach to their session style. You have a right to know, understand, and be educated on the theoretical orientation that your treatment is derived from.

Some types of theoretical orientations simply do not mesh well with Christian beliefs. Aspects of the theory might be used but be weary of a counselor who uses one of these theories for their main practice. Psychoanalysis provides a good example of the foundation of unconsciousness, this is not necessarily
against Christian beliefs but a psychoanalyst explains the unconscious through repressed sexual feelings. The family system, relationships, your overall experience with the world outside of yourself is largely determined by unconscious sexual urges in psychoanalysis. Consideration of this factor determines that Christian morality might not mesh with this framework.

While most of psychology is based on Freudian thought, it possible to counsel a Christian even though psychology is considered an analysis of abnormal behavior. The process of thinking, conceptualizing and formatting your ideas into your moral code and analyzing your cognitive dissonance may allow a person to match the inconsistency of their thoughts, words, beliefs and actions. Recognizing how your beliefs relate to your actions can change a person to live a more morally congruent life.

I know, this has nothing to do with bariatrics, weight loss surgery or weight loss--- yet.  I'll get to that part in the next post.  Next up, your personality and how it relates to your therapist.

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...