Post-Surgery Support Group for Bariatric Patients

Regarding the speed up rhythm of weight loss due to bariatric surgery, the patient needs to learn how to deal with his/her anxiety in a different way, what was before dealt by eating. This is not easy and there are no ready formulas to be given by psychologists. As there is no guarantee that new skills are learned to deal with pain, many patients continue with inadequate and dysfunctional behavior when facing hardship and stressful life situations. Psychological support in the postoperative period show itself essential. However, adherence to this support is still low.


Introduction
Regarding the speed up rhythm of weight loss due to bariatric surgery, the patient needs to learn how to deal with his/her anxiety in a different way, what was before dealt by eating. This is not easy and there are no ready formulas to be given by psychologists. As there is no guarantee that new skills are learned to deal with pain, many patients continue with inadequate and dysfunctional behavior when facing hardship and stressful life situations. Psychological support in the postoperative period show itself essential. However, adherence to this support is still low.
In general, obese people have difficulties to adhere to psychological treatment, as well as possibly deal with their emotional issues, causing absences and leak of contact with the psychologist. Thus, it is common to observe the patients not doing the post bariatric surgery counseling, despite the orientation of Ordinance 424 and 425 of March 19, 2013 [1] that states that the patient must see the psychologist monthly for at least 18 months after the surgery.
One of the main issues regarding the psychological evaluation before bariatric surgery and the postoperative counseling was the lack of agreement on the psychologist's performance [2,3]. However, in 2014, it was published by Brazilian Society of Metabolic and Bariatric Surgery (SBCBM) the first psychological care protocol in bariatric surgery to improve at least minimally the care patients receive, guiding the professionals who were involved in the attendance. However, there are many theoretical approaches in psychology with different schools of thought, resulting in different approaches in the treatment of obesity and in the guidelines and interventions to the patient before and after the surgery. This is another challenge to be thought about.
Thirteen psychologists of COESAS (Commission of the Associated Specialties) of SBCBM participated preparing the protocol. Among In this sense, support groups have the function to help people cope with stress related to common crisis, life transitions and stages of economic difficulties. Therefore, generally, such groups are intended to join patients with similar problems, willing to share their personal experiences and to engage them in developing a cohesive and supportive process [5].
For Schopler and Galinsky [5] it is expected that, in support groups, members have an active role in order to share their experiences, offering information, advice and encouraging the participation of other members. Moreover, the contribution of the coordinator tend to be varied, although it is usual that the group discussion is not structured and not focused on interpreting psychological factors. Thus, the therapist seeks to intervene helping members to confront what is not well adapted or pathological in the behavior of each other, such as acting in providing support valorizing positive abilities among patients and in strengthening their defenses.
Some of the positive effects mentioned by participants of support groups are the improvement in their social life, a higher level of knowledge about the issues discussed in the group, a better capacity of facing life situations, improvement in self-confidence, the reduction of fear and ambiguity, emotional relief and the reduction of hopelessness [5]. In support groups, there is support among group members themselves where they expose their difficulties and achievements, but do not necessarily work in depth their matters.
Aiming a low cost and satisfactory basis to the routine of patient's life, the group of postoperative psychological support proposed in this paper is based on sharing situations of weight loss, decrease of anxiety related to the pain as well as providing technical information experienced by patients. That is, the group is a resource on which emotional issues resulting from the surgical process and weight loss are worked, knowledge/acknowledgment of internal resources of each patient and share of experiences among members happen.

Psychological postoperative support group ethodology
The Psychological Postoperative Support Group to be reported, has been offered to patients after stomach reduction in a specialized service in obesity and bariatric surgery in Brasilia/Brazil. The clinic has a multidisciplinary team that consists of two psychologists who developed this project. This is a monthly, open and spontaneous group for patients undergoing bariatric surgery without delimitation of surgical period, without gender restriction and surgical technique. Two specific meetings are also open to family members or companions.
The group is structured in nine annual meetings with specific topics of discussion (Table 1) based on a psychoeducational approach [6]. The meetings last for 2 hours. After each meeting, new participants are invited to anonymously evaluate the work and provide suggestions for the next groups. In order to ensure the right to privacy, the clinic does not publish the identity of the participants.
The subjects were chosen from the clinical and academic experience of the authors, as well as group work is based on suggestions from researchers in health and other reference centers in bariatric surgery in Brazil [7][8][9][10]. The main demands of patients in the postoperative sought to be included in the discussed topics.

Experience Discussion
The bariatric population has difficulties to adhere to psychological treatment, as well as possibly to get in touch with their emotional issues. It is believed that the group format and some control of what will be discussed at the meetings can help patients in decreasing anxiety and increasing interest and willingness to participate. Following are the main contents that have been discussed in each meeting.

Meeting one -alcohol use: A research developed by the Medical
Center of the University of Pittsburgh in the United States showed that people undergoing bariatric surgery have a higher risk of becoming alcohol addicted. The beverage is metabolized differently in the body, one feels drunk faster and takes longer to return to sobriety [11]. In the postoperative, there is greater risk of exposure to alcohol because social life tends to be more intense. On the other hand, there is the lonely consumption of alcohol in an effort to relax, to forget loneliness, because of boredom. Special attention should be given to patients with prior report of consumption or abuse of alcohol and those patients with family report of alcohol or other drugs.
Meeting two -anxiety and depression: An interesting question regarding depression in patients eligible for bariatric surgery is that most patients seem to be depressed because of their weight and limitations related to it. In addition, when they take an active role in changing their lives through surgery, depression presents a visible decrease [12]. If depression increases in the postoperative, it is likely that other factors are related to sadness, such as conflicts that begin to appear and mourning the loss of the primordial relationship with food. Studies show that bariatric surgery can lead to a significant reduction in depression and anxiety [13]. If anxiety increases in the postoperative, it is likely that the rapid weight loss could have aroused hidden issues of obesity that were possibly still unexploited.
Meeting three -weight loss and self-esteem: An analysis of the literature seems to suggest that bariatric surgery improves self-esteem, self-confidence and expressiveness of the patients. These changes seem to be correlated to significant improvement in body image and weight loss satisfaction after surgery. However, residual dissatisfaction with body image due to the increasement and/or sagging skin has been reported as high and it is worrying [14].

Meeting four -exchange of compulsions:
The simple elimination of a symptom (food) through bariatric surgery without proper psychological work can lead the patient to a non-conscious choice of a new symptom to decrease the tension of the psychic apparatus. The person does not know what has been lost, there is no representation and therefore the tension cannot be eliminated through a secondary process. While the network representations are not made, the patient would continue to seek for an escape of this excess by a compulsive act [15]. We alert patients to a possible occurrence of other compulsive symptoms, such as games (bingo, cards), compulsive shop, abuse of drugs (especially alcohol), and excessive use of internet or video games and compulsive sex.
Meeting five -eating disorders: While longitudinal researches are needed to determine whether eating disorder is a cause, a correlation or a consequence of the worst weight loss results after surgery, studies suggest that eating disorders can be the worst prognosis and a suitable target for post-surgery intervention [16]. We warn patients to pay attention to the emotional triggers that have led them to eat inappropriately, and how much they are still present in the postoperative period.
Meeting six -weight recurrence: Behavioral factors that are more emphasized in the literature as those responsible for the recurrence of weight are related to excessive alcohol consumption, grazing, a sedentary lifestyle, a preference for mushy food, excessive consumption of sweet, and as a more common phenomenon in patients who do not participate in multidisciplinary counseling over the postoperative period [17]. Regarding cognitive factors, studies show the prevalence of self-destructive beliefs [18]. Incipient researches suggest as morbid obesity features: compulsion to food similar to the characteristics of drug addiction, worrying incidence of child sexual abuse in this population [18], immature affective regulation [19], dysfunctional dynamic family, suppressed aggression and hostility [20], in addition to obesity understood as a defense mechanism [21]. But studies are necessary that can investigate the presence or absence of these factors also in weight regain.
Meeting seven -body image: The dissatisfaction with body image, commonly perceived in obese patients, is strongly correlated with symptoms of depression, and this is particularly true for women, given the greater political control over their bodies [14,22]. The dissatisfaction related to weight, which can lead to a negative body image comes from a cultural emphasis in thinness and social stigma of obesity. Most studies about body image is focused in reflection about dissatisfaction, depreciation and distorted body image, under the influence of sociocultural factors [23].
Meeting eight -social and family support: Regarding obesity, studies claim that interventions based on family participation as well as the presence of a person providing social support, among other variables, facilitate weight reduction and maintenance of weight loss. Social support, especially members of the family core, has been considered a strong predictor of adherence to health treatment [24]. We alert patients and their families that there may be families that overly protect the patient of external overload and do not give them conditions to overcome frustrations; there are other families that may overload the patient and any carelessness in nutritional education is considered as a crime, a sin. The two familiar ways of working may spoil post-surgical results.
Meeting nine -sexual and emotional life: Obesity has been associated with changes in sexual function and undesirable changes in reproductive hormones in women. A recent study found that women who have undergone bariatric surgery had significant improvement in overall sexual functioning, the main reproductive hormones and psychosocial status [25]. In men, excess abdominal fat, cardiovascular disease, elevated blood lipids and type 2 diabetes have been associated with erectile dysfunction. Obese women report more sexual impairment than obese men. However, this complaint may be more related to low self-esteem, unsatisfactory relationships, social stigma, and other psychological problems.

Discussion and final considerations
The work of the Psychological Postoperative Support Group is going to its third consecutive year in the city of Brasilia/Brazil. This project began to be developed along the doctorate course of the first author.
The intention in the reported support group is that members take active roles to share their experiences and encourage the participation of other members. The psychologist acts as a group mediator in which, although there are predefined topics for discussion, allows the group to organize and bring what the members consider to be more relevant to discuss, with a minimum of psychological interpretations, and group analysis being more relevant than individual analysis.
As previously mentioned, the new participants are invited to anonymously evaluate the meetings. In this survey, we asked them to mention the negative and positive aspects of the work, as well as comments and suggestions for future meetings. Regarding the positive aspects reported by patients, stood out: (1) exchange of experiences, experiences and ideas among patients who had done the surgery; (2) psychoeducational approach of the meetings; (3) the spontaneity of the participants; (4) the relevance of the topics covered; (5) verification of common issues; (6) the establishment of new patient and group goals; (7) the development of objectives; (8) the identification of problems; (9) and reflection. It is noticed that friendship was created among the participants that have been maintained over the meetings besides the greater empowerment of patients, mutual support and autonomy to create other ways of meetings and exchange of ideas among them.
Regarding the suggestions for future meetings, the patients requested the participation of other specialties of the team. In one meeting the group could count on the participation of a physical education teacher. This request made us think about how each member of the multidisciplinary team is important to address the questions, concerns and guide patients and makes us plan future projects. Formally, the reported criticism was related to the days of the meetings (Saturday mornings) and informally difficulties of some patients in group relationship.
Certainly, group work is considered a protection factor for a number of emerging emotional problems in postoperative. For the support group, it is planned to include another annual meeting with the subject of post bariatric surgery pregnancy issue. The fact that patients experiencing situations similar to their peers make them feel understood. Moreover, participating in the group indicates a continuous movement of self-reflection, self-monitoring and self-care. A greater adherence to the psychological service in the postoperative period is considered a constant challenge.