Research on weight loss surgery: patients and therapists often do not talk about what really matters
Research on patient support after bariatric surgery uncovers a dilemma.
Picture yourself going to see your GP. You are presenting with a medical complaint, be it major or minor, and essentially with a feeling that something is wrong. The two of you only have a quarter of an hour to investigate. What do you want to happen in those fifteen minutes?
You want medical care, of course, but that is not all, according to Associate Professor Eli Natvik at the Western Norway University of Applied Sciences.
“During a consultation you have a profound need to be acknowledged in an holistic way – in terms of the disease or illness itself, certainly, but also when it comes to your fears and other things you may be struggling to articulate because your emotions are ambiguous and painful. This is essential if the consultation is going to be helpful to you,” she says.
“It’s quite simply about being listened to. Yet this is very difficult to achieve. As a patient, you feel like a distraction in a way: you turn up at the surgery with something that needs fixing. That’s an incredibly challenging starting point for a constructive conversation.”
Associate Professor Eli Natvik at the Western Norway University of Applied Sciences. (Photo: Private)
Consultations on film
Natvik is affiliated to Norse Feedback, a research and innovation project run by Førde Hospital Trust and the Western Norway University of Applied Sciences. The project looks at interactions between patients and therapists in the field of mental health.
Natvik wanted to apply methods and approaches from mental health to physical health and to investigate the outpatient support offered to people who have undergone weight loss surgery.
She contacted a group of patients scheduled to attend follow-up consultations a couple of years after their surgery. She invited them to participate in the project.
The consultations were videoed. She interviewed the patient before and after the consultation, while psychologist and fellow researcher Kristina Lavik interviewed the therapist. They watched the video of the consultation together, and the patient and therapist decided which parts of the video they would stop and comment on.
“When humans talk to each other there is a lot happening on the inside which the other person is unable to pick up on. We don’t always think to ask them about it either,” Natvik explains.
“There are moments over the course of a conversation where we feel that we connect – and others where we are in two different worlds. The aim of the videos and interviews was to gain an insight into the micro-processes that take place when two people talk to each other. We wanted to identify the helpful moments as well as the less helpful.”
We want to please each other
One of the patients Natvik met had lost a great deal of weight and changed his life drastically since his weight loss operation.
He was proud of the strict discipline he had introduced in respect of food and eating as well as the ambitious exercise regime he had established. But recently he had been unable to stick to his exercise programme because he had been suffering an acute illness.
The man went to the consultation at the obesity clinic feeling concerned. He feared that he may have gained weight. He only weighed himself at the hospital. Would the counsellor be annoyed with him? When that turned out not to be the case, he was able to relax for the rest of the consultation.
During the consultation he spoke about everything he had done to keep his weight in check, about the long and brisk walks. But he avoided touching on difficult emotions and the fear of weight gain that he had been experiencing.
The therapist offered praise and encouragement during the consultation and even went into enough depth to be able to identify a health issue that required medication.
Not a nice feeling
“I’m especially flexible with patients like him. It’s easier to go the extra mile for a patient who follows our advice, turns up to appointments, says he’s very happy with the support and feels seen,” the therapist says of the consultation.
However, had the man made a fuss about his condition or been critical of the treatment, it is not certain that she would have taken his symptoms as seriously, she reflects. She is not proud of this admission. She says it is “not a nice feeling, but that’s how it is.”
“Going by the book” is how Natvik describes the dynamic whereby the patient wants to do the right thing and the therapist wants to encourage the patient because the latter is sticking to the programme.
These conversations could potentially contain any number of helpful moments, but some patients may be reluctant to share difficult emotions or criticism.
Being sick often makes us angry and difficult
At the other end of the scale, we find the dynamic that Natvik describes as the “dead end”: consultations where both the patient and the therapist simply give up.
One woman she spoke to was critical of the support offered by the clinic. She did not feel she was given enough help with the extensive lifestyle changes required after her operation. The patient felt very alone.
She also became confused when meeting a new and unfamiliar therapist who did not start the consultation by weighing her – a procedure she had become accustomed to.
This minor change made her even more uncertain in that particular setting and fuelled her dissatisfaction.
The therapist felt under fire and accused of not doing her job properly. This meant she only did the bare minimum when meeting the woman.
As for the patient, she felt resigned after the consultation. Her frustration had got in the way of other things she really needed to talk about: her constant urge to comfort-eat and how tiring it was to resist that urge.
Despite her successful weight loss, the patient felt ashamed about her sugar cravings. Following the critical and irritable start to the meeting on her part, the conversation then shut down so that there was no safe space in which to raise the issue.
This made the consultation exhausting for both of them, and they just wanted to end it as quickly as they could.
“Being sick often also means being scared and angry. As a counsellor, you represent the system and therefore risk getting an earful,” Natvik says.
“If someone is having a really difficult time, it’s often difficult to help them. These patients are often unable to state their case in a way that evokes empathy, understanding and interest. Ironically, it’s much easier to help those who don’t need help as much.”
Conversations ebb and flow
Essentials can get lost in conversation with both agreeable and angry patients, but for different reasons. Then there are those conversations in between. Natvik describes their dynamic as one where the conversation switches between distance and presence.
One man she spoke to talked about how he knew and liked his therapist. Yet he felt reluctant to let her too close. He appreciated how she acknowledged the processes he had been through. She noted how much he had turned his life around, from being a loner suffering bullying to a high-functioning member of society.
A few things could still be better, however. He struggled with the way his weight fluctuated during holidays, for instance. But he did not want to bother the health service with that, he said.
For her part, the therapist was working hard to get under his skin. She was only partially successful.
She knew very well that an extensive intervention such as weight loss surgery, which had changed his entire anatomy and left him with a chronic deficiency disease, could not be as straightforward as he described it.
The problem was that her questions hit a highly sensitive spot. The patient was still associating food with guilt. This sense of guilt tended to flare up as soon as she asked him what and how much he was eating. The shame opened up a chasm between them which was difficult to cross.
Wanting to lighten the mood
“They keep nudging me. They want me to do better. Nobody else picks me up by the ears and drags me down this path, so I know it’s for my own good. They are there to help me. But there’s always that feeling that I should be doing better. I’m a bit ashamed of myself. This keeps coming back every time.”
These are the words of another patient interviewed by Natvik. And here she is getting to the heart of what is making these conversations so difficult: the vulnerabilities that are exposed when approaching the health service with a chronic and complex condition.
To mitigate this, the patient and therapist would often work together to create a light-hearted mood with smiles, humour and chats about the things that were going well: successful exercise programmes and meal planning.
Although stress, criticism, emotional turmoil and physical discomfort were unavoidable side-effects of the surgery, both parties were disinclined to bring up these difficult issues.
When they did raise them, it had a tendency to negatively impact the relationship and result in withdrawal, mistrust, shame or a feeling of failure between the two.
“But when we shy away from the difficult topics in a conversation, we also miss out on a chance to acknowledge them and address them properly. Rather than tackle the emotions head on, the therapist tended to steer the conversation towards advice and tips on actions that could be helpful. They were quick to want to fix things,” Natvik says.
Daring to be a fellow human
This tendency in the health service to look for the problem and seek a solution is only natural, but not always useful. If you concentrate on the medical issue and dodge the emotional aspect, the patient may be left feeling very alone in shouldering their significant burden.
For example, if a patient puts on weight and speaks of feeling disheartened and ashamed because of it, it is easy for the therapist to simply say that weight gain is completely normal – often in an attempt to reassure the patient.
“But that does not acknowledge the emotions they’re struggling with, and you risk severing the connection you have with them. You’re not fully there for them,” says Natvik.
“Therapists must dare to be humans, too. You must help the patient feel at home in the social setting that is the consultation. To many therapists, this may feel unprofessional, like deviating from professional standards. But it’s completely necessary.”
The health service has long overlooked the mental aspect of chronic conditions in such consultations,” Natvik believes. The relationship between patient and therapist is very much uncharted territory, in her opinion.
Not just body or just soul
To Eli Natvik, this study is merely the beginning of what she sees as a long process to improve human interaction in the health service.
So far, she and her colleagues have developed a workshop for health workers, integrating their findings from the research carried out amongst nursing students in Førde. They are now working to explore the issue further with students and staff in the health service.
“We used to think of care as something that happened at the bedside. But most modern hospital treatments are outpatient appointments – brief and infrequent appointments at that. It’s crucial, therefore, that we learn from the field of mental health when it comes to interacting with people,” Natvik contends.
But how do we ensure that these consultations are successful when they are both brief and infrequent? And what if the illnesses the patients present with, such as clinical obesity, are complex and persistent?
“It is possible to build relationships even during these brief encounters. That is what we need to learn more about,” says Natvik.
“I think the key is to be curious about the other person. I have to open up a little in order to make room for the other person.”
Eli Natvik et al.: The patient-practitioner interaction in post bariatric surgery consultations: an interpersonal process recall study. Disability and Rehabilitation, 2022. (Abstract) Doi.org/10.1080/09638288.2022.2152876