As part of my private practice, I will often perform psychological evaluations on patients who are interested in weight loss surgery (WLS). This is not to be confused with liposuction, a cosmetic procedure generally done for appearance purposes. WLS is a medical treatment for obese people who often have serious health concerns such as Diabetes and hypertension. You can learn more about WLS here.
WLS is a fairly controversial area of medicine, not only for the medical field, but the allied professions (such as psychology) and the public. Because a patient who has the surgery is required to change his or her diet and eating habits, many professionals and laypeople balk at the idea that surgery is "needed." Many think that obesity is simply a lack of will power, and if you can eat appropriate amounts of food after the surgery, why not simply do that right now?
Pro-surgery people point to the fact that WLS can treat multiple medical conditions simultaneously, improve a person's self-esteem, and prevent further health problems. Because the stomach is smaller after the surgery, a person can feel satiated with only a small amount of food. And with statistics to back up its purported success, the pro-surgery community questions why someone who has had multiple failed attempts at weight loss should suffer needlessly. This is my stance.
One of the goals of the psychological evaluation is to help a person understand and articulate their relationship with food. "The surgery will certainly change your body," I tell every potential surgery candidate, "but it won't necessarily change your thoughts and feelings about food. Your diet has to remain constant from here on out, regardless of how you are feeling psychologically."
We all self-medicate our emotions at one point or another, whether it be by dint of food, cigarettes, alcohol, drugs, sex, shopping, etc. For the post-surgery patient, however, using food as any sort of coping skill leads not only to a lack of weight loss, but also a host of physical problems. One patient described it for me:
"I was doing great for about 3 months, had lost a boatload of weight. My wife and I had a huge fight about the dog or her overcooked fish or something stupid, and I was so angry. I turned to food to ease the anger, had a box of donuts. I threw up for about 6 hours, thinking I was going to die, and then spent the next 6 hours throwing up some more hoping I would die."
The patients that I see for evaluation sign a form stating they understand that, depending on their psychological profile, they may not be immediately approved for surgery. At the behest of the surgeons that I work with, I can't say more about the details of the evaluation and what I'm looking for in a person's psychological profile, but I believe all of us can understand that people who are currently binge eating cannot be approved for surgery without intervention prior to having the procedure.
On a bright, sunny Monday morning, in a gorgeous Park Avenue surgeon's office, I sat in one of the pristine consultation rooms, sipping a piping hot Dunkin Donuts hazelnut coffee and reading The New York Times. "Is Dr. Rob Dobrenski the Greatest Social Scientist of our Time?" the fantasized headline of the Health section read. "Yes he is," I thought. "He truly is."
Laura disrupted this meditation by pointing out that I needed to actually work while using their office space and that she had a patient who needed to be evaluated. "Dr. James is very hesitant to perform the surgery on her, but he wants an expert opinion on this."
"Expert," I thought. "Damn straight."
The patient was "Betty," an early 20's college student who sported her school's sweatshirt along with blue jeans and a colossal bookbag which practically shook the room when she threw it to the floor. "If you ever change careers, doc, don't take up Engineering," she panted as she sat down. Betty completed the requisite paperwork for the evaluation and we began to talk about her psychological history, her prior attempts to lose weight, what had worked and what had not, and of course her relationship with food. At only 5 feet, 3 inches tall but well over 250 pounds, Betty admitted that she was currently exhibiting symptoms of Bulimia Nervosa, which included both binge eating and self-induced vomiting. And yet, she still wasn't losing weight, which just confused her. I explained to her that, unlike Anorexia Nervosa, people who suffer from Bulimia are not necessarily thin, but engage in extreme and unhealthy behaviors to lose weight. She went on to say that she knew she had a problem, and that she viewed the surgery as her last hope to "be normal." She teared up at this, and said that she hates to be in public, fearing that everyone was staring at her for being so overweight.
Eating disorders can be extremely debilitating, but fortunately are often treatable by medication, psychotherapy, or a combination of both. Betty needed to be sold on the idea that while surgery will ultimately be very helpful to her, her psychological difficulty needed to be treated first. Otherwise, not only would she be set up for failure, but also for potential medical complications from the excessive food consumption and self-induced vomiting.
"Betty, I hear you when you say you want to be "normal." And you've got some medical problems here that this surgery would eliminate. I want you to have it, but I can't approve you for it at this time."
Rubbing her eyes, now red from crying, she looked puzzled. "But why?"
"Because you have a psychological condition known as Bulimia Nervosa, and it's considered an obstacle to successful surgery. We need to get you some help with this first so that when we do go ahead with surgery for you, you'll have a much greater likelihood for success."
"But the surgery will make me skinny," she protested, a bit adamantly.
"No, the surgery will allow you to feel full with a small amount of food, which will allow you to lose a large amount of weight. That doesn't mean you'll necessarily be skinny, but you'll be healthy and in the normal weight range. However, you said that you eat when you get upset, and we need to help you stop that behavior, because it will completely sabotage the surgery, and you could actually be worse off than when you started."
"That's ridiculous," she said, her voice growing louder. "How the hell do you know that?"
"I understand you're disappointed, but just think about it. If we could get you a helpful therapist, or maybe some medication to help with your mood..."
"Medicine?! Are you crazy? I'm not taking medicine!"
"I'm not saying that medicine is required, but Dr. James would certainly agree with me that you need to get at least some form of help before we proceed."
"So are you saying I fail?" she stared suspiciously.
"I'm just saying that your approval is pending until we've gotten you hooked up with appropriate help."
"Pending? Pending?? You've got to be kidding me! I thought this was a simple formality," she yelled, standing up now and pointing an angry finger at me. "I'll be damned if I let some shrink get in the way of my surgery!"
She stormed out, slamming the door behind her, causing the New York Times with the imaginary headline about how fantastic I am flap about for a second or two.
"Um, Dr. Dobrenski," Laura peeped a few minutes later, only one eye visible from the crack in the door that she created. "Betty stormed out of the office, murmuring something on the way out."
"She was pretty upset, understandably. What did she say?"
"She said that she was 'going to get her gun'."
Other than my experience with Mike, I'd never had a direct threat put upon me.
"Did she say who she planned to use the gun on?"
"I see. When you say 'me,' do you mean to say that she said 'Rob Dobrenski'?"
"No, she said 'the skinny punk kid who thinks he's fucking Freud.'"
I couldn't think of anyone else who fit that description.
"Dr. Dobrenski, I told the Greg (the office manager), and he's already called the cops."
Therapist Rule: Before calling in enforcements, consider whether or not an attack on another person is imminent. Was she merely letting off steam? Since she had already left, I had to assume that what she said implies imminence.
"Can I talk to Greg?" I asked.
"He's on the phone now with the Dr. James at the hospital. Dr. James is wondering how you could let a situation get out of control like this in his office."
So he wasn't actually concerned about my life, just his office.
Stupidly, I walked out into the waiting area, just in case Betty had returned with her firearms (no sense putting off the inevitable), to find Greg looking panic-stricken. "It's alright, it's alright" he gasped. "The police said to just call back if she shows up with a gun."
I took refuge in the little kitchen area, secretly hoping to find a bottle of Dewer's as the realization that someone might want to kill me began to sink in. After about 15 minutes, Laura came in. "Dr. Dobrenski? Betty is here...unarmed. She wants to talk to you."
"How do you know she's unarmed?"
"She promised that she didn't get her gun."
Well, if a promise from someone who was a stranger less than an hour ago didn't put me at ease, what would?
I went out to the waiting room, where a clearly distraught Betty was waiting. Should I have frisked her? I escorted her back to the consultation room, briefly considering that she might pistol whip me to death once inside.
"I'm...sorry," she said.
"I can understand your distress, but I don't quite get why your reaction was so extreme."
"I, I don't know. I'm just so tired of being heavy, I just want to stop being so big. It effects me in so many ways, and I just saw you as another thin person telling me 'no.'"
"I apologize if I came out that way," I said. "But you're not being told 'no.' Losing weight won't change everything in your life, and I just think you need some help beforehand."
"I know, I thought about it, and maybe I could see a therapist."
"That would be fine, most people do much better with their weight loss program if they have a support program built in. And I'm sorry again if I didn't explain my position correctly or led to feel that we wouldn't help you. Would you like to make an appointment with me?"
"No offense, Dr. Dobrenski, but I was hoping to work with a, um, larger woman who might understand me better. Can you refer me out?"
"Absolutely. No more references to guns in the future?"
She giggled a bit and wiped her eyes, clearly in a better place. "Fair enough."
I gave Betty names and numbers for every non-skinny female colleagues that I could think of. Betty apologized again for threatening to take my life, and as the day came to an end, the sun setting over the Hudson River, I basked in glow of knowing that I made the world a better place today. It is a better world with me alive...isn't it?