Can Body Group Therapy after Bariatric Surgery be Effective to Avoid Weight Regain? A Clinical Experience

Introduction:Weight regain may occur with bariatric surgery and it depends on nutritional, psychological and surgery-related factors. The persistence of body shape concern and uneasiness after weight loss is considered a risk factor for weight regain. Weight loss after Bariatric surgery determines change of the cognitive-behavioral component of Body Image, but not the emotional one. The aim of this study is to show that Group psychotherapy can repair the body image emotional component achieving weight maintenance. Method:30 patients: mean age 38 SD ± 10, 71; 18 women, 12 men; mean Body Mass Index (BMI) 48 SD± 8,31 suffering from onset obesity, were enrolled in this study. All participants were evaluated before and after bariatric surgery. They underwent body group psychotherapy to reinforce body image and self Results:Results of body group therapy were: a significant increase of the ability to use body in the relation with the others and a better tendency to accomplish new experiences. No differences were found among groups in self reinforcement process related to sleeve and gastric by-pass. Conclusion:Psychotherapy is an effective tool in changing body Image and reinforcing self. This process can be more effective in achieving and structuring weight stability and realize obesity healing.


Introduction
Weight regain may occur with all three of the most common procedures (Roux-en-Y gastric bypass, sleeve gastrectomy and gastric banding), and it depends on nutritional, psychological and surgeryrelated factors. There are very few studies directly investigating the clinical factors determining weight regain. Poor outcome after the first surgery may happen as follow-up studies underline stressing the importance of psychiatric or psychological factors in inducing it [1]. The persistence of body shape concern and uneasiness after weight loss determining the inability to recognize one-self as an individual with own desire and capacity, is considered a risk factor for weight regain [2]. Psychotherapy is the most useful instrument to reconstruct body image and achieve weight maintenance [3][4][5][6][7].
This study describes a clinical experience of body group therapy after bariatric surgery showing that psychotherapeutic treatment is necessary to reinforce the patient identity in order to prevent weight regain.

Material and Method
30 patients: mean age=25-26; 18 women, 12 men; mean Body Mass Index (BMI) 48 SD ± 8.31suffering from onset obesity, were enrolled in this study. They had five years of various and unsuccessful diets. They were assessed for bariatric surgery: sleeve or gastric by-pass. Patients were referred to the Eating Disorder and Obesity Unit of the School of Medicine "Federico II" Naples by the Bariatric Regional Units. They signed a written voluntary informed consent form before entering the study. All participants were evaluated before bariatric surgery in according to the standard procedure for psychological/psychiatric assessment and took part of the nutritional follow-up.
At follow-up time (t1) the results are: weight loss with a sufficient reduction of BMI: MBMI=33.6 and SD ± 8.58; good clinical and nutritional conditions. Bariatric type of operation: 20/30 sleeve, 10/30 gastric by-pass; absence of surgical complications in the short and long period, absence of Post-surgical Eating Avoidance Disorder (PSEAD); sufficient ability to cope with nutritional program for bariatric surgery; change of Eating behavior. All patients underwent Body Group psychotherapy after 8 month from sleeve or gastric by-pass. They were divided in two groups (15/30 M age=25.6). Treatment lasted 8 months, session occurred once in two weeks for two hours. Patients showed a significant increase of the ability to use body in the relation with the others and a better tendency to accomplish new experiences.

Clinical Case
Every group is formed by a therapist leader and 15 participants. The overt task of the group is to achieve weight maintenance. The group foundation is based on the communication about feelings and physical perception coping with the peculiar nutritional program after surgery. This work in progress reconstructs or substitutes a reliable relation model in the area of the affective bond and determines a real enhancement of subjects' coping capacity strengthening their own self-

Journal of Obesity & Weight loss Therapy
esteem. These two components enable the group members to elaborate the negative body image and invest in the new slim body image as an agent of change. The therapist pushes participants to describe the new eating behavior and the sensation of satiety supported by the effective increase of satiety feeling induced by surgery that allows a new regulation of primary need hunger-satiety. In post-operation period, patients need to follow a liquid, semi-liquid, semi-solid and solid diet, conditioned by the surgical reduction of the gastric pouch. This experience brings to memory the event of weaning and allows the therapist to help group members to go again through the weaning experience of childhood: surgical patient-child is fed by the sufficient holding therapist-mother. Group therapy becomes the space where the reminder of weaning experience can be elaborated in a new relationship reconstructing the affective bond. It is an instrument to become conscious of and to take possession of the new body, passing the separation anxiety determined by change. The group, taking care of subject's body change, learns non-verbal communication in the relationship to the environment and realizes the reinforcement of member's personality structure. The new awareness reduces the feeling of body detachment and the necessity of social withdrawal as a mechanism of defense against family and social judgment. Moreover, it produces a decrease of body uneasiness increasing the ability to cope with the nutritional program felt as the instrument of maintaining the new body image and the new identity. The group field becomes the place where participants begin to exchange emotions and thoughts about the new personal experience in the relationship with the environment. They are able to elaborate the feeling of a new possibility to be a subject able to achieve his own desire and projects. The therapist induces this experience using specific body exercises and discussing the resulting emotions. These sessions bring out retrieval of the psycho-soma split built throughout childhood as defence of the patients' feeling of not to be able to be loved because of obesity. The new feeling of being an individual reinforces the desire of weight maintenance that becomes the necessary instrument of recognizing one self and for this reason cannot be lost.
Clinical observations, six months from the end of group, by interviewing the members, emphasize that weight maintenance becomes steadier and also the ability to experience oneself in relation to the environment has a pattern of continuity.

Discussion
Weight loss is not sufficient to determine a change of body image emotional component related to primary need hunger-satiety and, therefore, it cannot repair the pathological affective bond built throughout the primary experience of childhood and the corresponding procedural memory. This last influences food intake as mechanism of defence from the feeling of being inadequate in the affective area [8]. The lack of an integrated experience between body and mind conducts to the psycho-soma split [9]. This mental condition makes the association with a psychological therapy which aim is to try to repair the quality of Self-development increasing the ability to feel oneself as an individual with own motivation and desire necessary [10]. In this study it is performed body group psychotherapy because it allows to enlarge the subject's insight and in the same time elaborate the relation with oneself through the experiences with others represented by the members of the group, using non-verbal communication [11,12]. Group experience leads the members of the group to learn new ways of being, recognizing body as a part of their own identity. Furthermore, body group therapy allows to feel and recognize the desire and imagination of the own body parts. The members of the group describe the experience of the typical nutrition after bariatric surgery. The physical sensation related to it puts in evidence the psychological strength of the specific bariatric nutritional rehabilitation and the possibility of developing new behavioural strategies [13].

Conclusion
The peculiarities of weight loss process resulting from sleeve or gastric by-pass and in general from bariatric surgery, connected to the particular change of mind reconstruction process can be more effective in achieving and structuring weight stability. The acceptance of the new body image resulting from the psycho-soma unit can be one of the factors avoiding weight regain.