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Gestalt Therapy & Bariatric Patients: A Confluence of Dental Aggression

And The Relational Turn

Charlie Bowman, MS, LCSW, LMFT, LCAC

December 6, 2014 Chelsea Studios

New York, NY

This presentation and the manuscript, A Year of Bariatric Weight Loss: Sorting Facts and Feelings

Before and After Weight Loss Surgery, are available to NYIGT members at

http://www.bowmancounseling.com/resources/

© Charlie Bowman, 2014

Case Study

Charles Bowman 52 y.o. w/m/m at surgery date Max Weight: 390# Max BMI: 54.4 Surgery Date: 12/7/2007 Surgeon: John Huse, MD (SOEMBS) Hospital: St. Vincent (BSCOE) Procedure: Open Roux-en-Y Family Hx: + for obesity, diabetes, HBP, arthritis, cancer, alcoholism Mental Status Pre-Surgery: anxious, agitated, depressed, obsessed with obesity, defeated http://www.bowmancounseling.com/resources/

“The unborn baby is dependent in every respect upon the mother-for getting the material for physical growth, oxygen, warmth, transportation; immediately after birth he must provide his own oxygen. Soon he must contribute to his own food intake, by sucking the milk and providing a considerable amount of warmth for himself. As time goes on, he becomes more and more self-supportive. He learns to communicate, to crawl and walk, to bite and chew, to accept and reject. So the development continues and the child realizes some part of his potential for existence.”

“…To mobilize his potential and to ensure proper maturation, the child has to overcome many frustrations. In the healthy child these frustrations will mobilize the resources which are innately available.”

“When either the frustrations are too great for the child to cope with or he is, spoiled and deprived of the opportunity to "do for himself," he will develop his own individual brand of psychopathology.”

“…Finally this deep split between our biological and our social existence leads to more and more conflicts and "holes." The holes are the main characteristics of the incomplete personality.”

Introductory Note to the 1971 Edition of PHG

Who Qualifies for Bariatric Surgery? Classification BMI(kg/m)

Principal cut-off points

Additional cut-off points

Underweight <18.50 <18.50 Severe thinness <16.00 <16.00 Moderate thinness 16.00 - 16.99 16.00 - 16.99 Mild thinness 17.00 - 18.49 17.00 - 18.49

18.50 - 22.99 Normal range 18.50 - 24.99 23.00 - 24.99

Overweight ≥25.00 ≥25.00 25.00 - 27.49

Pre-obese 25.00 - 29.99 27.50 - 29.99

Obese ≥30.00 ≥30.00 30.00 - 32.49

Obese class I 30.00 - 34-99 32.50 - 34.99 35.00 - 37.49

Obese class II 35.00 - 39.99 37.50 - 39.99

Obese class III ≥40.00 ≥40.00

Common Procedures Ø  Roux-en-Y Gastric Bypass (Gold Standard) Ø  Adjustable Gastric Banding (Lap Band) Ø  Vertical Sleeve Gastrectomy (Gastric Sleeve) Ø  Biliopancreatic Diversion with Duodenal Switch (DS)

Common Procedures Ø  Roux-en-Y Gastric Bypass (Gold Standard) Ø  Adjustable Gastric Banding (Lap Band) Ø  Vertical Sleeve Gastrectomy (Gastric Sleeve) Ø  Biliopancreatic Diversion with Duodenal Switch (DS)

Why Gestalt Therapy?

Ø Morbid obesity recovery is a dramatic O/E adjustment

Ø  Surgical intervention changes the field - B=ƒ(P,E)

Ø  Fits an “alimentary” model of experience and growth

Ø  Support is fundamental. Awareness of needs, and healthy aggressing is fundamental to success

Ø  Relational success = long term surgery success

Ø  Integrates with other disciplines – complex process

Simple Beginnings in Therapy

Breath work supporting oximeter training for diaphragmatic breathing

Post-surgical eating requires chewing each bite 50 times. Perls quipped that chewing every bite until liquid for a year would replace therapy.

Working through inner conflicts supports behavioral compliance

Dramatic, rapid changes in self-image requires support for adjustment through periods of disorientation

Ø  Internal Support ü  Breathing

ü  Body awareness

ü  Learning to chew

Ø  External Support ü  Support groups!

ü  Medical support

ü  Social support

Ø Grieving loss of food/binges

Ø  Setting realistic expectations

Progression: Early Post-Surgery

Ø Practicing phenomenology

Ø  Addiction transfer

Ø  Coping with vulnerability

Progression: Late Post-Surgery

Gestalt Cycle of Experience

“Every utterance, every thought, feeling, sensation, every moment that happens in our consulting rooms is variably mutually influenced (and influencing). Nothing happens that arises pristinely from ‘within’ the therapist or ‘within’ the patient.

- Lynn Jacobs, 2009 A classical gestalt therapy view of growth, which places emphasis on awareness, authenticity, agency, healthy boundaries, experimentation, self-support and choice. A relational gestalt therapy view of growth places an emphasis on empathy, connection, dialogue and sensitivity to the vulnerabilities that accompany relationality.

-Peter Cole, 2014

The Relational Turn - 45°, 90° or 180°?

Support & Therapy Over Time

Surgical Support Behavioral Support

Amount of

Support

Time in Months (Post-surgery)

Multi-disciplinary Integration

Ø Bariatric Hospital Team Ø ASMBS Certified Surgeon Ø Psychologist Ø Dietician/Nutritionist

Ø Exercise Physiologist Ø Bariatric “Life Coach” Ø Physical Therapist Ø Psychotherapist

The  way  a   team  plays  as  a  whole  deter0ines   its  success.  You  may  have  the  g9eatest  bunch  of  individual  stars  in  the  world,  but  if  they  don't  play  together,  the  club  won't  be  wor>h  a  dime.                  

                   ~  Babe  Ruth  

Resources A Year of Bariatric Weight Loss: Sorting Facts and Feelings Before and After Weight Loss Surgery, Charlie Bowman, 2011 http://www.bowmancounseling.com/resources/ Mindless Eating: Why We Eat More Than We Think, (2006). Brian Wansink, New York: Bantam Dell. This book identifies how to lose weight through awareness of purchasing, serving, eating habits and orientation to food. Body of Awareness: A Somatic and Developmental Approach to Psychotherapy, (2001). Ruella Frank, Cambridge: Gestalt Press. Demonstrates how movement plays a critical role in a developing self-awareness. Intended to help therapists, new or advanced, to enhance their skills of attunement. Gestalt Therapy: An Introduction to the Basic Concepts of Gestalt Therapy. (2010). Hanne Hostrup, Copenhagen: Museum Tusculanum Press. Clinical introduction to basic concepts in Gestalt therapy. Gestalt Therapy for Addictive and Self-Medicating Behaviors, (2012). Phil Brownell, New York: Springer Publishing. Technical use of Gestalt therapy in addictions treatment. Gestalt therapy focuses on unblocking the barriers clients experience to being fully

alive and present. It emphasizes dynamic awareness and contact with one's internal and external environments. Particular attention is paid to the development of creative adjustments and the relationship that develops between therapist and client in the moment. For more information and training opportunities go to http://www.indygestalt.com