Weight stigma makes it more difficult for people to enjoy physical activities, nourish their bodies, and manage stress, which contributes to poorer health outcomes and lower quality of life.33,34 For example, one study showed that, regardless of actual body mass index, people experiencing weight stigma have significantly increased risk of developing an illness or dying.35
Factors specific to WLS. WLS may lead to significant changes in eating habits, and some patients experience a sense of loss, particularly if eating represented one of their primary coping strategies—this may represent a heightened emotional vulnerability for developing AUD.
The fairly rapid and substantial weight loss that WLS produces can lead to sweeping changes in lifestyle, body image, and functional factors for many individuals. Patients often report profound changes, both positive and negative, in their relationships and interactions not only with people in their support network, but also with strangers.36
After the first year or 2 post-WLS, it is fairly common for patients to regain some weight, sometimes in significant amounts.37 This can lead to a sense of “failure.” Life stressors, including difficulties in important relationships, can further add to patients’ vulnerability. For example, one patient noticed that when she was at her thinnest after WLS, drivers were more likely to stop for her when she crossed the street, which pleased but also angered her because they hadn’t extended the same courtesy before WLS. After she regained a significant amount of weight, she began to notice drivers stopping for her less and less frequently. This took her back to her previous feelings of being ignored but now with the certainty that she would be treated better if she were thinner.
Patients also may experience ambivalence about changes in their body size. One might expect that body image would improve after weight loss, but the evidence is mixed.38 Although there is some evidence that body image improves in the short term after WLS,38 other research indicates that body image does not improve with weight loss.39 However, the evidence is clear that the appearance of excess skin after weight loss worsens some patients’ body image.40
To date, there has been no research examining treatment modalities for this population. Because experiences common to individuals who have had WLS could play a role in the development of AUD after surgery, it is intuitive that it would be important to address these factors when designing a treatment plan for post-WLS substance abuse.
Group treatment approach
In 2013, in response to the increase in rates of post-WLS addictions presenting to West End Clinic, an outpatient dual-diagnosis (addiction and psychiatry) service at Massachusetts General Hospital, a specialized treatment group was developed. Nine patients have enrolled since October 2013.
The Post-WLS Addictions Group (PWAG) was designed to be HAES-oriented, trauma-informed, and run within a fat acceptance framework. The HAES model prioritizes a weight-neutral approach that sees health and well-being as multifaceted. This approach directs both patient and clinician to focus on improving health behaviors and reducing internalized weight bias, while building a supportive community that buffers against external cultural weight bias.41
Trauma-informed care42 emphasizes the principles of safety, trustworthiness, and transparency; peer support; collaboration and mutuality; empowerment; and awareness of cultural, historical, and gender issues. In the context of PWAG, weight stigma is conceptualized as a traumatic experience.43 The fat acceptance approach promotes a culture that accepts people of every size with dignity and equality in all aspects of life.44
Self-care emphasis. The HAES model encourages patients to allow their bodies to determine what weight to settle at, and to focus on sustainable health-enhancing behaviors rather than weight loss. Patients who asked about the PWAG were told that this group would not explicitly support, or even encourage, continued pursuit of weight loss per se, but instead would assist patients with relapse prevention, mindful eating, improving self-care, and ongoing stress management. Moving away from a focus on weight loss and toward improvement of self-care skills allowed patients to focus on behaviors and outcomes over which they had more direct control and were more likely to yield immediate benefits.
All of the PWAG group members were in early recovery from an SUD, with a minimum of 4 weeks of abstinence; all had at least 1 co-occurring mental health diagnosis. A licensed independent clinical social worker (LICSW) and a physician familiar with bariatric surgery ran the sessions. The group met weekly for 1 hour. The 8 weekly sessions included both psychoeducation and discussion, with each session covering different topics (Table). The first 20 minutes of each session were devoted to an educational presentation; the remaining 40 minutes for reflection and discussion. In sessions 2 through 8, participants were asked about any recent use or cravings, and problem-solving techniques were employed as needed.
The PWAG group leader herself is a large person who modeled fat acceptance and follows the HAES approach; she led the group using both this experience and her specialized clinical training. As is the case with other addictions recovery treatment modalities, clinicians with lived experience may add a valuable component to both the program design and patient experience.
After the first 8 sessions, all members expressed interest in continuing as an ongoing relapse prevention and HAES support group, and they reported that meeting regularly was very helpful. The group continued with the LICSW alone, who continued to share HAES-oriented and fat acceptance information and resources that group members requested specifically. Over time, new members joined following an individual orientation session with the group leader, and the group has revisited each of the psychoeducational topics repeatedly, though not in a formally structured way.