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Cognitive and Behavioral Practice 20 (2013) 529–543
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Cognitive Behavioral Therapy for Bariatric Surgery Patients: Preliminary Evidence

for Feasibility, Acceptability, and Effectiveness
Stephanie E. Cassin, Ryerson University
Sanjeev Sockalingam, University of Toronto and Toronto Western Hospital
Susan Wnuk, Rachel Strimas, and Sarah Royal, Toronto Western Hospital
Raed Hawa, University of Toronto and Toronto Western Hospital
Sagar V. Parikh, University of Toronto

Bariatric surgery is the most effective treatment for extreme obesity; however, 20% to 50% of patients begin to regain their weight within
the first 1.5 to 2 years following surgery. Despite some psychosocial factors predicting postoperative weight loss and weight regain,
psychosocial interventions are not routinely offered in bariatric surgery programs. In this paper, we describe a 6-session cognitive
behavioral therapy (CBT) intervention for preoperative and postoperative bariatric surgery patients with maladaptive eating behaviors
or thought patterns, which can be delivered either in person or by telephone. In addition, we describe a small pilot study (n = 8) designed
to examine the feasibility and acceptability of the CBT intervention, as well as its effectiveness in improving eating pathology and
psychosocial functioning. Most pilot study participants reported improvements in binge eating severity, emotional eating, and
depression from pre- to posttreatment, and all participants provided positive qualitative feedback regarding the intervention.

T HE World Health Organization has declared obesity

a global epidemic (Chopra, Galbraith, & Darnton--
Hill, 2002). Rates of obesity in Canada and the United
States are 24.1% and 34.1%, respectively (Shields, Carroll,
& Ogden, 2011). The associated medical comorbidities,
including type 2 diabetes mellitus, obstructive sleep
apnea, hypertension, and hyperlipidemia, pose a signif-
icant burden on the health care system (Bray, 2004).
Bariatric surgery, a procedure that restricts the stomach's
capacity for food and/or limits the absorption of food, is
the most effective treatment for patients with class II
obesity, defined as a body mass index (BMI) between 35
and 39.9 kg/m 2, and class III obesity, defined as a BMI of
40 kg/m 2 or greater (World Health Organization, 2000).
The National Institute for Health and Clinical Excellence
(2006) in the United Kingdom recommends bariatric
surgery for individuals with extreme obesity, and for those
with a BMI greater than 35 kg/m 2 and significant
obesity-related medical comorbidities (e.g., type 2 diabetes
mellitus, sleep apnea). According to the American Society
Keywords: cognitive behavioral therapy; telephone therapy; bariatric
surgery; gastric bypass
1077-7229/12/529-543$1.00/0
© 2012 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
for Metabolic and Bariatric Surgery, approximately 200,000
individuals in the United States received bariatric surgery in
2007, with Roux-en-Y gastric bypass being the most
frequently performed procedure (Mechanick et al.,
2009). The Roux-en-Y gastric bypass surgery involves
creating a small stomach pouch from a portion of the
stomach and attaching it directly to the small intestine. By
effectively bypassing a large portion of the stomach and the
duodenum, fat absorption is significantly reduced
(Mechanick et al.). Patients who undergo this procedure
lose an average of 60% to 70% of their excess body weight
within the first 2 to 3 years, and experience dramatic
improvements or complete resolution of many of their
medical comorbidities (Buchwald et al., 2004; Shah, Simha,
& Garg, 2006).
While bariatric surgery is effective in reducing weight
and improving most obesity-related comorbidities, it does
not directly target the underlying psychological factors
that potentially contribute to the development and
maintenance of obesity. In addition to genetics and
biological factors, psychological factors, such as depres-
sion, anxiety, negative affect, and emotion dysregulation,
are critical determinants of weight because many people
overeat in an attempt to regulate their emotions (Gariepy,
Nitka, & Schmitz, 2010; Luppino et al., 2010; Whiteside
et al., 2007). According to recent prevalence estimates,
33.7% of bariatric surgery candidates have a current Axis I
530 Cassin et al.
disorder, and lifetime rates are even higher (67.8%;
Mitchell et al., 2012). The most common current
diagnoses are anxiety disorders (18.1%), affective disor-
ders (11.6%), and binge eating disorder (10.1%; Mitchell
et al.). In addition to those meeting diagnostic criteria for
an eating disorder, a much higher percentage endorse
maladaptive eating behaviors such as emotional overeat-
ing, grazing, and loss of control over eating (Kalarchian,
Wilson, Brolin, & Bradley, 1998; Saunders, Johnson, &
Teschner, 1998). Depressive symptoms account for sig-
nificant variance in binge eating severity among bariatric
surgery patients (Azarbad, Corsica, Hall, & Hood, 2010).
Moreover, binge eating, grazing, uncontrolled eating, and
postoperative loss of control have been shown to predict
poorer weight loss and greater weight regain following
bariatric surgery (Ashton, Heinberg, Windover, & Merrell,
2011; Canetti, Berry, & Elizur, 2009; Colles, Dixon, &
O'Brien, 2008; Kalarchian et al., 2002; Niego, Kofman,
Weiss, & Geliebter, 2007; Sockalingam, Hawa, Wnuk,
Strimas, & Kennedy, 2011; White, Kalarchian, Masheb,
Marcus, & Grilo, 2010).
Despite psychological factors contributing to obesity,
psychosocial interventions are not routinely offered in
bariatric surgery programs. Approximately 20% to 50% of
patients begin to regain their weight within the first 1.5 to
2 years following bariatric surgery (Shah et al., 2006) and
experience relapse of obesity-related comorbidities such
as type 2 diabetes mellitus (DiGiorgi et al., 2010). Untreated
psychological factors might be one of the contributing
factors to weight regain. In order to improve psychosocial
functioning and maintain weight loss, individuals need to
learn coping skills such as scheduling healthy meals and
snacks at regular time intervals, planning pleasurable
alternative activities to overeating, planning for difficult
eating situations, and reducing vulnerability to emotional
overeating by solving problems and challenging negative,
counterproductive thoughts (Apple, Lock, & Peebles,
2006a, 2006b).
Cognitive behavioral therapy (CBT) is a skills-based
psychosocial intervention that has been shown to improve
binge eating and promote short-term weight loss in obese
individuals; however, weight loss is modest (typically less
than 10% of body weight) and it is not typically sustained
during the follow-up period (Agras, Telch, Arnow,
Eldredge & Marnell, 1997; Cooper et al., 2010; Foreyt &
Poston, 1998). Although CBT on its own may be
insufficient for sustained weight loss in severely obese
individuals, it could be a beneficial adjunct treatment to
bariatric surgery. It has been suggested that CBT could
improve some of the psychosocial factors that have been
shown to predict bariatric surgery outcomes, and thus,
may enhance weight loss and psychosocial functioning
(Kalarchian & Marcus, 2003). Although no randomized
controlled trials have been conducted to date, a recent
open trial conducted with 243 bariatric surgery candi-
dates found that a brief (four session) preoperative CBT
group was effective in reducing binge eating behaviors in
bariatric surgery candidates (Ashton, Drerup, Windover,
& Heinberg, 2009). The CBT group protocol included
topics such as binge eating, emotional eating, mechanical
eating, food records, stimulus control, stress manage-
ment, cognitive restructuring, surgery preparation, and
surgery expectations. Participants who demonstrated a
positive response to the CBT intervention (defined as
reporting zero eating binges and a having a score on the
Binge Eating Scale in the minimal range following CBT)
had an enhanced surgical outcome, with greater loss of
excess body weight 6 and 12 months postsurgery com-
pared to participants who did not demonstrate a positive
response to CBT (Ashton et al., 2011). Thus, preliminary
research in bariatric surgery populations suggests that a
brief CBT intervention delivered in person in a group
format during the preoperative phase can reduce binge
eating and enhance weight loss. Two questions that
remain are whether improvements extend to other
domains of psychosocial functioning (e.g., mood, emo-
tional overeating), and whether CBT is also effective in
the postoperative phase given that bariatric surgery
patients often express the need for additional support
following the initial period of rapid weight loss in order to
maintain behavioral changes.
One challenge in delivering psychological interventions
to bariatric patients is that bariatric surgery programs often
serve large catchment areas. According to data compiled at
a Canadian Bariatric Surgery Program, patients travel an
average of 138.5 kilometers or 86.1 miles (range: 2.0 to
1734.0 kilometers or 1.2 to 1077.5 miles) so many cannot
feasibly attend weekly therapy sessions (Sockalingam et al.,
2012). Travel distance is inversely associated with postop-
erative attrition, further reinforcing the need for psycho-
logical treatment modalities that can overcome this barrier
(Lara et al., 2005; Moroshko, Brennan, & O'Brien, 2012).
Newer methods of delivering CBT, such as telephone-
based CBT (Tele-CBT), allow for greater access to
psychological treatments because they can be delivered
during the evenings and weekends, eliminating the need to
take time off work, find child care, and travel to hospital
appointments (Hart & Hart, 2010). Telephone-based CBT
has been shown effective in treating various forms of
psychopathology, including depression and anxiety (Lovell
et al., 2006; Ludman, Simon, Tutty, & Von Korff, 2007;
Parikh et al., 2009; Tutty, Sprangler, Poppleton, Ludman, &
Simon, 2010). In addition, patients who receive telephone-
based CBT for the treatment of depression and anxiety
report comparable levels of treatment satisfaction to those
who receive face-to-face CBT (Lovell et al., 2006; Tutty,
Ludman, & Simon, 2005) and have lower rates of attrition
(Mohr et al., 2012), suggesting that telephone-based CBT is
 CBT for Bariatric Surgery Patients
an acceptable form of treatment. Given that mobility issues
can pose substantial problems for extremely obese in-
dividuals, many of whom live a considerable distance from
treatment centres, it is also imperative to explore whether
telephone-based CBT is a feasible and effective option.
The Present Study
We sought to adapt a CBT intervention focused on
coping skills to improve eating behaviors that would be
suitable for both preoperative and postoperative bariatric
surgery patients and could be delivered either in person
or by telephone. We also sought to conduct a small pilot
study to examine the feasibility and acceptability of the
CBT intervention and its effectiveness in improving eating
pathology and psychosocial functioning.
Description of CBT Protocol for Bariatric
Surgery Patients
Several experts in the fields of eating disorders and
obesity were contacted and asked to provide recommen-
dations for cognitive-behavioral client workbooks and
clinician manuals suitable for use with individuals engaging
in maladaptive eating (e.g., binge eating, emotional
overeating). Members of the Toronto Western Hospital
Bariatric Surgery Program (TWH-BSP) Psychosocial Team,
including psychiatrists, psychologists, and psychometrists
with master's-level training in clinical psychology, reviewed
the recommended resources and selected the client
workbook and clinician manual that appeared to be the
most suitable for bariatric surgery candidates, Preparing for
Weight Loss Surgery (Apple et al., 2006a, 2006b). Preparing for
Weight Loss Surgery is part of the “Treatments That Work”
series published by Oxford University Press. The client
workbook and clinician manual contain a variety of
cognitive behavioral techniques that are informed by
research on maladaptive eating patterns, and have been
shown to improve eating habits. Given its empirical basis
and applicability to bariatric surgery patients, Preparing
for Weight Loss Surgery provided the foundation for the
CBT intervention. In addition, the four-session CBT group
protocol developed by Ashton and colleagues (2009) to
help improve binge eating in preoperative bariatric surgery
patients informed the CBT intervention, as did workbooks
published by Burns (1999), Greenberger and Padesky
(1995), and Linehan (1993). Specifically, we adapted some
handouts from these workbooks, including thoughts re-
cords to challenge negative automatic thoughts and lists of
pleasurable activities to attempt when experiencing the
urge to overeat.
Members of the TWH-BSP Psychosocial Team reviewed
Preparing for Weight Loss Surgery and then met as a group to
adapt the manual based on their clinical experience with a
variety of patients in the program and the clinical context of
531
the TWH-BSP. The revisions focused primarily on making
the manual suitable for a wide variety of patients within the
program (e.g., preoperative and postoperative patients,
with and without psychiatric diagnoses, from a variety of
educational backgrounds). A six-session CBT protocol was
developed that could be delivered to both preoperative and
postoperative patients. Given that the program serves a very
large catchment area, some modifications were made so
that the protocol could be delivered either in person or by
telephone. For example, all handouts and worksheets were
in electronic format so they could be e-mailed to patients.
Patients were instructed to read the handouts before each
CBT session so they would be familiar with the concepts
being discussed during the session. Individuals who
received CBT by telephone were asked to have the
handouts in front of them during telephone CBT sessions,
and to complete the worksheets electronically and e-mail
them back to the CBT therapist prior to the next session so
the homework could be reviewed during the CBT session.
To make the client workbook suitable for patients from a
wide variety of educational backgrounds, the language in
the workbook was simplified to a 10th grade reading level,
graphics were added, concepts were simplified, worksheets
were modified (e.g., cognitive restructuring worksheet),
and supplementary handouts and worksheets were added
(e.g., list of potentially pleasurable activities, common
cognitive distortions in bariatric surgery patients).
Overview of CBT Protocol for Bariatric Surgery Patients
Session One: Introduction to CBT and the Cognitive Behavioral
Model of Overeating
The goals of Session One are to introduce CBT, set
treatment goals, present a cognitive behavioral model of
some factors implicated in overeating and weight gain,
and discuss the impact of overeating on thoughts,
emotions, and behaviors (Table 1).
Session One begins with an overview of CBT. Patients are
informed that CBT is a short-term, collaborative, skills-or-
iented approach to treatment that focuses on the here--
and-now, or the factors that currently maintain difficulties
such as maladaptive eating habits. The patient and clinician
work together to establish treatment goals (e.g., to reduce
binge eating or emotional overeating, to plan ahead for
meals, to increase water intake, to reduce caffeine intake, to
increase physical activity). Although specific treatment goals
vary across patients, the general goal of CBT is to replace
maladaptive thoughts and behaviors with more adaptive
ones, and consequently, to improve emotional functioning.
The remainder of Session One is spent discussing a
cognitive behavioral model of overeating and weight gain
(Figure 1). Factors contributing to overeating and obesity
are discussed, including social/cultural factors, biological
factors, and psychological/behavioral factors. Potential
532 Cassin et al.

Table 1
Overview of Cognitive Behavioral Therapy Protocol

Session Goals CBT Techniques

1 Introduce CBT Socialization into treatment
Set treatment goals Goal setting
Present a cognitive behavioral model of some factors implicated Psychoeducation
in overeating and weight gain
Help patients understand the impact of overeating on thoughts, Socialization into the CBT model
emotions, and behaviors
2 Help patients understand the importance of a regular pattern of Psychoeducation
eating and weighing
Teach patients how to keep track of their eating Self-monitoring (food records)
Teach patients how to keep track of their weight Self-monitoring (weekly weight chart)
3 Help patients understand why eating has been so pleasurable Psychoeducation
Help patients understand the importance of planning other Behavioral activation (planning pleasurable activities)
pleasurable activities that do not involve food
Help patients understand the importance of self-care activities Self-care
4 Identify the places, people, and foods that make it challenging Identify triggers for maladaptive eating
to eat healthy
Teach patients problem-solving skills to handle challenging Problem-solving
food situations
5 Teach patients problem-solving skills to overcome challenging Problem-solving
problems
Identify counterproductive thoughts that lead to maladaptive Psychoeducation (cognitive distortions)
behavior
Change counterproductive thoughts into more adaptive ones Cognitive restructuring (thought records)
6 Preoperative Patients:
Explore ambivalence about bariatric surgery Decisional balance
Prepare for surgery by having all supplies and social supports Problem-solving
in place
Teach patients about changes to eating following surgery and Psychoeducation
normative reactions to the surgery, and how to access help if
problems develop following the surgery
Review progress on treatment goals Goal setting
Review CBT skills to continue using following treatment Relapse prevention
Postoperative Patients:
Explore ambivalence about maintaining long-term lifestyle changes Decisional balance
Review progress on treatment goals Goal setting
Review CBT skills to continue using following treatment Relapse prevention

social/cultural factors include interpersonal relationships
(e.g., few social relationships, limited social support,
interpersonal conflict, teasing, abuse), social stressors
(e.g., raising children, financial stress, work/school stress,
unemployment), and cultural norms (e.g., culture that
places a high value on thinness while simultaneously
promoting consumption of calorically dense foods).
Potential biological factors include demographic variables
(e.g., age, sex, ethnicity), genetics, body composition
(e.g., muscle mass), and metabolic rate. Potential
psychological/behavioral factors include eating patterns,
emotional overeating, and physical inactivity.
After discussing the contributing factors to overeating
and obesity, the discussion turns to the implication of
weight gain. Therapists elicit from patients some of the
adverse effects they have experienced, such as health
problems (e.g., type II diabetes mellitus, hypertension,
hyperlipidemia, obstructive sleep apnea), worry about
developing health problems, weight-related stigma, con-
flict in relationships, or negative emotions (e.g., depres-
sion, anxiety, frustration, shame, anger). Some of these
adverse effects (e.g., worry about developing health
problems) lead to restrictive dieting in an attempt to
lose weight, which paradoxically leads to overeating,
whereas others (e.g., interpersonal conflict) lead more
directly to overeating in an attempt to alleviate negative
emotions or distract from problems. The CBT model is
used to help the patient understand the vicious feedback
cycle that is created, whereby overeating is reinforced
by temporary relief or pleasure, but then followed by
negative emotions which increase vulnerability to addi-
tional overeating.
 CBT for Bariatric Surgery Patients
Social/Cultural Factors
Abuse & teasing
Relationships
Worry About Stigma Regarding
Health Obesity
Attempts to Diet
Shame, Guilt, Regret,
Failure, Depression
Figure 1. Cognitive behavioral model of overeating describing factors contributing to weight, consequences of weight gain, and feedback
cycle that perpetuates overeating.
For homework, patients are asked to complete a
personalized cognitive behavioral model of the factors
that have led to the development and maintenance of
their overeating and obesity.
Session Two: Using Food Records to Normalize Eating
The goals of Session Two are to help bariatric patients
understand why it's important to start a regular pattern of
eating and to teach them how to keep track of their eating
using food records.
Patients are informed that a regular pattern of eating
helps to break the links between thoughts, feelings,
overeating, and weight gain. Patients typically report
overeating in response to cravings, emotions, or simply
having tasty food around. “Eating by the clock” helps to
retrain hunger signals so that eating behaviors are
separated from cues that are not tied to hunger or
fullness, such as emotions or cravings. Patients are advised
to eat three small meals and two to three small snacks per
day, and to eat meals and snacks within 3 to 5 hours of
each other.
Patients are introduced to food records—a daily
journal that is used to track eating patterns, thoughts,
and feelings. They are asked to record the time
and location of each eating episode, the amount and
type of food or liquid consumed, the type of eating
533
Biological Factors Psychological/Behavioral
Factors
Age, sex, ethnicity
Food intake & eating
Genetics patterns
YOUR WEIGHT
Conflict Negative
Emotions
Overeating
Brief Relief or Pleasure from
Food
episode (e.g., snack, meal, binge, or graze), whether they
experienced loss of control over eating, and the context
of the eating episode (e.g., situation, thoughts, feelings).
Food records are important because they help to identify
patterns in eating (e.g., skipping meals, high-risk periods
for overeating), to change patterns in eating (e.g., reduce
portion sizes and grazing between meals, increase protein
and water consumption), and to monitor progress and
motivate patients to keep on track.
In addition to monitoring food intake, patients are
informed about the importance of weighing themselves
regularly and keeping track of their weight. Some
individuals weigh themselves too frequently, sometimes
multiple times per day, and have strong reactions to
small changes in their weight that may be attributed more
to fluid or sodium intake than to changes in body
composition. In contrast, others avoid the scale altogether
because the numbers are upsetting and, as a result, they
risk additional weight gain because they do not have a
mechanism in place to receive regular feedback about
their current eating habits. Bariatric surgery patients are
advised to weigh themselves once each week on a specific
day and at a specific time so that they can get a more
precise comparison from week to week. They are also
encouraged to record their weight each week so they can
monitor changes that take place before too much time
534 Cassin et al.
passes. Patients’ current weighing practices are discussed,
and barriers to increasing or decreasing the frequency of
weighing are problem solved.
For homework, patients are asked to keep a daily food
record and to weigh themselves at one predetermined
time during the week. Patients are also encouraged to
graph their weekly weight to have a visual record of their
progress. These homework tasks continue for the
duration of therapy.
Session Three: Pleasurable Alternatives to Overeating
The goals for Session Three are to help patients
understand why eating has been so pleasurable and why it
is important to plan other pleasurable activities that do
not involve food.
Given that overeating often provides a sense of
pleasure, albeit short-lived, in order to overcome obesity
it is important to replace the maladaptive relationship
with food with other pleasurable and meaningful activities
that do not involve food consumption. Not only can other
pleasurable activities help to cope with the urge to
overeat, but they can also help to enrich the patient's
life away from food. Individuals with depressive symptoms
are also provided with the rationale for behavioral
activation as an additional reason to engage in pleasur-
able activities. Patients are provided with recommenda-
tions regarding alternative activities such as choosing
activities that require physical movement over stationary
activities (e.g., going for a walk, doing yoga), choosing
activities that are incompatible with eating (e.g., having a
hot shower, giving yourself a manicure, playing guitar,
working in the garden), and choosing realistic activities
that are feasible to do in the moment (e.g., inexpensive,
do not require much preparation, can be used in a variety
of contexts such as first thing in the morning, in the
middle of the work day, or home alone in the evening).
Patients are given a long list of potentially pleasurable
activities from which to choose (adapted from Linehan,
1993), and they are also encouraged to come up with their
own ideas.
Along with pleasurable activities, the concept of
self-care is also discussed in Session 3. Given that lack of
self-care can increase the risk for emotional overeating,
patients are advised to practice good self-care habits such
as exercising regularly, socializing regularly, practicing
good sleep hygiene, limiting consumption of alcohol and
caffeine, and avoiding illicit psychoactive substances.
For homework, patients are asked to create a
personalized list of 10 to 20 activities that they would be
willing to attempt, and to choose 2 activities to try in the
coming week. They are also asked to choose 2 areas of
self-care to address (e.g., reducing caffeine intake, making
social plans with a friend). Patients continue with these
homework tasks for the duration of therapy.
Session Four: Problem-Solving High-Risk Eating Situations
The goals of Session Four are to identify the places,
people, and foods that make it challenging to eat healthy,
and to learn problem-solving skills to handle challenging
food situations.
Bariatric surgery patients frequently report that they
engage in mindless eating—eating on the couch while
watching TV, in the car while driving, or at a desk while
working. Once these places become associated with food, it
can be very difficult to separate them. In addition, because
food is typically consumed very quickly, an excessive
amount of food is consumed before fullness sets in. Given
that patients must consume very small portions of food at a
very slow pace following surgery in order to prevent
vomiting and unpleasant gastrointestinal symptoms, they
are encouraged during CBT to eat at a slow pace while
sitting down at a table that is designated for eating.
In addition to identifying challenging places to eat
properly, patients also identify challenging people—for
example, attending catered work events with colleagues,
going out for dinner with friends who also have a sweet
tooth, or living in a household where take-out meals are
the norm. Finally, patients identify foods that often trigger
the urge to overeat. Completely avoiding all trigger foods
can lead to feelings of deprivation and potentially eating
binges, so patients are taught to eat these foods in
moderation at times when they are not vulnerable to
emotional overeating (e.g., sharing a dessert with several
friends when out at a restaurant). They are also taught
to plan ahead and bring healthier alternatives to events
(e.g., night out at the movies, weekend away at the cottage).
For homework, patients complete several worksheets
to problem-solve challenging eating situations.
Session Five: Challenging Counterproductive Thoughts
The goals for Session Five are to learn problem-solving
skills to overcome challenging problems, to identify
counterproductive thoughts that lead to maladaptive
behavior, and to change these counterproductive thoughts
into more adaptive ones.
People sometimes turn to overeating when they have a
difficult problem to solve because it provides a temporary
distraction when a real solution seems too complicated to
try. In order to handle problems more effectively, patients
are taught problem-solving skills such as identifying the
problem in concrete terms, brainstorming all potential
solutions without censoring, evaluating how realistic and
helpful each solution would be, choosing one or a
combination of the solutions, committing to following
through with the solution, and evaluating the outcome.
The remainder of the session focuses on counterpro-
ductive thinking. The concept of cognitive distortions is
introduced—ways of thinking about situations that can
intensify negative emotions and lead to maladaptive
 CBT for Bariatric Surgery Patients
behaviors such as overeating. Several relevant examples
are shared with patients, such as all-or-nothing thinking
(e.g., “If I have one bad food, I've totally blown my diet”;
“If I don't reach my goal weight, I'm a failure”),
overgeneralization (e.g., “I always blow my diets”;
“Nothing I try ever works”), discounting the positive
(e.g., “I only lost weight because of the surgery” without
acknowledging lifestyle changes such as healthier food
choices and regular exercise), fortune-teller error (e.g., “I
won't be able to keep the weight off”), mind reading (e.g.,
“Everyone judges me harshly because of my weight”),
catastrophizing (e.g., “If I have one bad food, then I'll
regain all of my weight), emotional reasoning (e.g., “If I
feel fat, then I must have gained weight”; “If I feel like a
failure, then I must be a failure”), and “should”
statements (e.g., “I should have lost more weight by
now”; “I should have lost as much weight as my friend who
had bariatric surgery”). Individuals with psychiatric
conditions such as mood or anxiety disorders are given
some additional examples of cognitive distortions that
might contribute to feelings of depression or anxiety.
Patients are taught to challenge counterproductive
thoughts using cognitive restructuring worksheets
(adapted from Burns, 1999; Greenberger & Padesky,
1995) and are informed that the goal of cognitive
restructuring is to develop a more neutral or benign
interpretation of a situation, and as a result, reduce the
intensity of the negative emotions and engage in more
adaptive behaviors.
For homework, patients complete several problem-
solving worksheets to work through difficult problems,
and cognitive restructuring worksheets to challenge coun-
terproductive thoughts.
Session Six (Preoperative): Preparing for Bariatric Surgery
The final session differs depending on whether CBT is
being delivered during the preoperative or postoperative
period. The goals for Session Six for preoperative patients
are to explore ambivalence about bariatric surgery,
prepare for surgery by having all supplies and social
supports in place, discuss changes to eating following
surgery and normative reactions to the surgery, and
discuss how to access resources if problems develop
following the surgery.
It is common for patients to feel ambivalent or
conflicted about undergoing bariatric surgery. On the
one hand, they might feel excited about the potential for
significant weight loss, improvement to medical condi-
tions, increased energy, and improved mobility. On the
other hand, they might feel anxious about the risks of
surgery, commonly experienced physical discomfort
following eating after surgery (e.g., “dumping syndrome”;
vomiting), physical pain, nutritional deficits, and the
potential for weight regain. The substantial changes that
535
are required to eating habits following surgery might also
contribute to a sense of loss because food can no longer
be used to meet emotional needs. In addition, bariatric
patients might worry about how their bodies will appear
after significant weight loss (e.g., excess skin) or how
people will respond to their weight loss. During the
session, some time is spent recording these considerations
on an ambivalence worksheet (i.e., “possible negative
things about surgery” and “possible positive things about
surgery”), and the worksheet is completed for homework.
If patients are overly optimistic about the outcome of
surgery and have not considered some of the potential
negative aspects (e.g., complications, excess skin), it is
important to have a discussion of the potential risks and
benefits so they have realistic expectations prior to
undergoing bariatric surgery.
In order to increase the probability of a positive
surgical outcome, the discussion then turns to preparing
for bariatric surgery. It is critical that patients have
arranged for several people to provide emotional and
practical support leading up to and following bariatric
surgery (e.g., drive home from surgery and to follow-up
appointments, purchase first-aid supplies, prepare meals,
vitamins, and medications). Patients are encouraged to
create a list of all of the people who are able to provide
support, all of the supplies they will need in the weeks
following the surgery, and the tasks that have been
assigned to each person.
In the final part of the session, the discussion turns to
managing problems that can develop following bariatric
surgery, such as vomiting, diarrhea, “dumping syndrome,”
disordered eating (e.g., fear of certain foods, subjective
eating binges), or mental health problems (e.g., depres-
sion, anxiety, or addictive behaviors). The CBT strategies
that could be helpful if these problems arise are reviewed
in the final session. For example, patients can use food
records to monitor food intake and help make sense of
why eating and digestive problems might have developed.
Cognitive restructuring skills can be used to challenge
anxious or depressive thoughts. Pleasurable activities can
be planned to reduce the urge to overeat. The TWH-BSP
Psychosocial Team follows patients for 5 years following
the surgery, and they are encouraged to consult with the
team if any significant problems arise between scheduled
appointments.
Session Six (Postoperative): Keeping on Track Following Bariatric
Surgery
The structure of this session is similar to Session Six for
preoperative patients; however, the session is modified
somewhat to make it more suitable for postoperative
patients. Rather than discussing how eating will change
and the problems that might develop following bariatric
surgery, patients are asked about their personal
536 Cassin et al.
experiences following bariatric surgery. Rather than
exploring ambivalence about bariatric surgery, the session
focuses on ambivalence about maintaining long-term
lifestyle changes.
The first year following surgery has been referred to as
a “honeymoon period” because, for many patients, weight
seems to drop off with little effort. As weight loss plateaus,
some patients feel pessimistic about their ability to achieve
their goal weight or keep the weight off, particularly if
they have failed to sustain weight loss after many previous
diets. In order to maintain the weight loss, patients must
persist with behavior changes such as healthy eating and
physical activity. Long-term changes require persistent
effort, and patients sometimes feel ambivalent about
sustaining behavioral changes. On the one hand, they feel
good about the weight they have lost and their improved
physical health, but on the other hand, these changes
require significant and sustained planning, time, and
effort. In addition, patients might feel happy about fitting
into a smaller clothing size, but feel very dissatisfied with
the excess skin that worsens with greater weight loss.
During the session, time is spent recording these
considerations on an ambivalence worksheet (i.e., “pos-
sible negative things about making long-term lifestyle
changes” and “possible positive things about making
long-term lifestyle changes”), and the worksheet is
completed for homework. If patients are feeling pessi-
mistic about their ability to maintain long-term lifestyle
changes, cognitive restructuring can be used to challenge
cognitive distortions, and problem-solving can be used to
overcome barriers to maintaining progress. CBT strate-
gies that could help to maintain progress are reviewed in
the final session and patients are encouraged to continue
practicing the skills on their own following treatment.
Case Illustration: Patient A
Patient A was a 28-year-old woman who was referred for
bariatric surgery by her family physician. At the time of the
initial assessment, she had a BMI of 43.1 kg/m 2 and some
obesity-related medical comorbidities including type 2
diabetes mellitus and joint pain. She met criteria for major
depressive disorder in partial remission and mild gener-
alized social phobia. Although she did not meet the
frequency criteria for binge eating disorder, she did
experience regular eating binges and also engaged in
emotional overeating. Her primary motivations for bariat-
ric surgery included improving health, becoming more
physically active, and improving physical appearance.
Session 1
Patient A reported that her treatment goals were to stop
eating in response to her emotions, and to improve her
mood. She identified with the CBT model of overeating and
reported a number of factors that contributed to the
development and maintenance of her weight issues. The
members of her immediate family were obese and ate a lot
of heavily processed and fast food. She became obese in
early adolescence, and also experienced her first major
depressive episode around the same time. She reported
that she was teased for her weight from a young age, and
that her parents often used food as a way of providing her
with comfort. She believed that this early experience taught
her to rely on food to fulfill her emotional needs. She
reported that she rarely attempted to reduce her weight
through dieting, and thus, did not identify with the link
between dieting and overeating in the cognitive behavioral
model. The maintenance factors she did identify with
included negative emotions leading to overeating, which
provided temporary pleasure and escape from negative
emotions, and in turn led to feelings of guilt, depression,
and hopelessness. These feelings subsequently increased
her vulnerability for additional overeating.
Session 2
The importance of recording food intake and
monitoring weight regularly was discussed in Session 2.
Patient A had already been meeting occasionally with a
staff dietician and was keeping food records, albeit
inconsistently. She expressed ambivalence about keeping
food records because she felt very ashamed about her
eating binges and emotional overeating, and (perhaps
due, in part, to her social anxiety) was also concerned
about being judged or criticized regarding her eating
habits. A review of the food records suggested that she was
eating at regular time intervals throughout the day, as
recommended by the dietician. However, she was often
overeating in the evening following her dinner. The
rationale behind keeping food records was reiterated to
Patient A, and she was reassured that the purpose of
the food records was not to criticize her eating habits.
She was praised for specific positive eating behaviors
(e.g., consistently eating a well-balanced breakfast, eating
“by the clock” during the day). The focus of the food
records was on identifying high-risk situations that lead to
binge eating and emotional overeating, including the
cognitive, emotional, and situational precipitants to over-
eating. In addition, she was asked to record her thoughts
and emotions when weighing herself weekly.
Session 3
Patient A reported that she previously had a lot of
hobbies, but she lost interest in many of them when she
became depressed and she gave up other activities due to
her weight. Given Patient A's limited financial resources
and tendency to overeat late in the evenings, it was
important to brainstorm pleasurable activities that were
 CBT for Bariatric Surgery Patients
inexpensive and could be attempted while home alone in
the evenings. Her list of pleasurable activities included
knitting, painting, making inspirational collages, and
giving herself a manicure and pedicure. She was also
informed that, in addition to distracting her from the
urge to overeat, planning pleasurable activities could also
help to improve her depressive symptoms. She was
encouraged to do some mastery activities to give her a
sense of accomplishment. During the discussion on
self-care activities, Patient A noted that the two areas she
was having the greatest difficulty with were physical
exercise and caffeine intake. In order to improve her
self-care and increase her mastery activities, she set a goal
of walking halfway home from work rather than taking
public transit directly to her doorstep. She also met the
staff dietician to work on tapering her caffeine intake and
increase her water consumption prior to surgery.
Session 4
The food records that Patient A had been keeping
indicated that she frequently ate in her car, at her office
desk, in front of the TV, or in her bedroom while using
her laptop. Thus, the focus of Session 4 was on reducing
vulnerability to mindless eating by consuming meals and
snacks in designated eating areas. She was initially
reluctant to do so because she felt that she did not have
enough time to take a lunch break at work, and she also
disliked eating in the staff lunch room because she
worried that her coworkers would watch her closely while
eating. She decided to start by eating lunch at her desk
while her computer monitor was turned off and other
distractions were put to the side. She then began eating
her afternoon snack in the lunch room when fewer
coworkers were around. She noted that her dining room
table at home was completely covered with paperwork
that overwhelmed her, including documents that needed
to be filed and some bills that needed to be paid. The
rationale for behavioral activation (i.e., scheduling
mastery activities) was revisited, and Patient A set a goal
of taking 20 minutes each night to organize the paper-
work so that she could clear off her eating space.
Session 5
Patient A reported that she frequently felt “stressed
out” about her limited financial resources, and her food
records also indicated that these concerns occasionally
precipitated emotional overeating. Her financial stress
was escalating as her surgical date approached because
she was going to have to take unpaid time off work while
she was recovering from surgery and also purchase
required vitamins and other supplies following surgery.
The problem-solving worksheet in Session 5 focused on
brainstorming ways to increase her financial resources.
537
The remainder of the session focused on identifying
cognitive distortions in the automatic thoughts she had
been recording in her food records and articulating
during therapy. One of her most common automatic
thoughts included, “I'll never be able to reach my goal
weight.” The primary evidence she was relying on was the
fact that her weight had been steadily increasing.
However, she also acknowledged that she had never
made a sustained effort to improve her eating habits or
increase her physical activity, she could not “fortune-tell”
the outcome of bariatric surgery, she had successfully
changed some other behaviors when she put her mind to
it (i.e., quit smoking), and she had already started making
some small changes to her eating habits. The automatic
thought, “I'll never be able to reach my goal weight”
seemed to stem from a deeper, core belief (“I'm a
failure”) that contributed to her depressive symptoms.
This link was highlighted for Patient A, and she was
informed that cognitive restructuring is a coping skill that
can help to challenge counterproductive thoughts related
to eating and weight, as well as depressive thoughts more
broadly.
Session 6
Patient A had already been planning for her surgical
date throughout treatment and had made arrangements
for many supports to be in place for her following surgery.
Given that she had already met with many members of the
multidisciplinary team, she was also aware of the many
supports that were available to her through the program if
she experienced any physical or emotional issues follow-
ing surgery. Thus, the final session focused primary on
discussing her ambivalence about bariatric surgery. On
the one hand, she was very excited about the prospect of
improving her health, mobility, and physical appearance.
However, she also had concerns about surgical complica-
tions, postoperative pain, and excess skin. Aside from her
immediate family and a few close friends, she did not want
to tell anybody about her surgery and she felt uncertain
about how to respond to comments about her weight loss.
She also felt a sense of loss when thinking about having to
give up some of her favorite foods and changing her
eating behaviors when dining out with friends. Finally, she
worried that she might have a depressive relapse if surgery
was ineffective or if she regained the weight she lost. Each
of these concerns was normalized and processed in
session. Psychoeducation was provided concerning surgi-
cal complications. Some time was spent brainstorming
ways to respond to comments about weight loss (e.g., “I've
been making some big changes to my eating and also
getting more exercise”). She was encouraged to continue
completing food records and cognitive restructuring
worksheets following surgery in order to enhance her
538 Cassin et al.
surgical outcome and reduce the risk of relapse.
Ultimately she decided that the potential benefits of
surgery outweighed the potential costs.
The Pilot Study
Overview of Pilot Study Participants and Procedures
Pilot study participants (N = 8) were recruited from the
TWH-BSP, and had either been approved for surgery or
had already received surgery. Toronto Western Hospital is
the centralized assessment and follow-up centre for the
University of Toronto Collaborative Bariatric Surgery
Program—a Bariatric Centre of Excellence that comprises
three hospitals (i.e., Toronto Western Hospital, Toronto
East General Hospital, and St. Michael's Hospital). To be
eligible for bariatric surgery, patients must be over the age
of 18 and have a BMI greater than 40 kg/m 2, or greater
than 35 kg/m 2 with significant obesity-related medical
comorbidities (e.g., type 2 diabetes mellitus, sleep apnea).
In order to be eligible for the pilot study, participants had to
be fluent in English, have access to a telephone and a
computer with Internet connection, and have the capacity
to provide informed consent, and could not currently have
severe psychiatric issues (e.g., active suicidal ideation, active
psychotic symptoms) that preclude participation in psycho-
logical treatment. Individuals with clinically significant
eating pathology, such as binge eating disorder, were
permitted to participate in the pilot study.
All patients in the TWH-BSP undergo an interdisci-
plinary assessment as part of the presurgical screening
and suitability assessment, which includes assessments
with a surgeon, nurse practitioner, social worker, dieti-
tian, and either a psychometrist (an individual with a
master's degree in clinical psychology trained to perform
psychodiagnostic testing and psychological treatment
under supervision), a psychologist, or a psychiatrist. In
addition, bariatric patients continue meeting with mem-
bers of the interdisciplinary team for 5 years following
surgery. Dietitians identified patients who they felt were in
need of psychological treatment due to emotional eating,
binge eating, or negative thoughts that had the potential
to sabotage their progress (e.g., “I should have lost more
weight by now”; “I'll never reach my goal weight”). These
patients were contacted by an individual with a master's
degree in psychology and recruited into the CBT pilot
study. Psychiatrists, psychologists, and psychometrists with
supervised training in CBT delivered the CBT interven-
tion and met regularly as a group to discuss the sessions
for the duration of the pilot study. The six CBT sessions
were delivered weekly and each session lasted 50 to
60 minutes. The CBT intervention was delivered either
preoperatively (n = 2) or postoperatively (n = 6), and
either in person (n = 6) or by telephone (n = 2). The
structure and content of the sessions was identical
regardless of whether the intervention was delivered in
person or by telephone. We varied the timing of CBT
delivery (preoperative, postoperative) and the mode of
delivery (in person, telephone) for the pilot study in
order to examine if the CBT protocol would be relevant,
feasible, and acceptable across a variety of contexts.
Qualitative feedback regarding the CBT protocol was
solicited from patients at the end of the final CBT session.
The study was approved by the institutional Research
Ethics Board, and all pilot study participants provided
informed consent to have their data used for research.
Measures
Mini International Neuropsychiatric Interview (MINI; Sheehan
et al., 1998)
Participants were administered the MINI, version 6.0,
by a psychiatrist, a psychologist, or a psychometrist. The
MINI is a structured psychiatric interview with good
reliability and validity for diagnosing psychiatric disorders
(Sheehan et al., 1998). The modules of the MINI are used
to diagnose mood, anxiety, psychotic, eating, ADHD and
substance use disorders. The MINI 6.0 was supplemented
with two modules to assess binge eating disorder and
lifetime generalized anxiety disorder based upon criteria
from the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV-TR) criteria.
Patients completed the following measures 1 week prior
to starting CBT (pretreatment) and then again immedi-
ately following the last CBT session (posttreatment).
Eating Disorder Examination–Questionnaire (EDE-Q; Fairburn
& Beglin, 1994)
The EDE-Q is a 41-item self-report measure that
assesses psychopathology associated with the diagnosis
of an eating disorder. Only three of the EDE-Q items
assessing binge eating and loss of control were included in
the current study. Specifically, participants were asked,
“Over the past 7 days…how many times have you eaten
what other people would regard as an usually large
amount of food given the circumstances? On how many of
these times did you have a sense of having lost control
over eating? On how many days have such episodes of
overeating occurred (i.e., you have eaten an unusually
large amount of food and have a sense of loss of control at
the time)?”
Binge Eating Scale (BES; Gormally, Black, Daston, & Rardin,
1982)
The BES is a 16-item self-report measure that assesses
the presence of binge eating behavior. The items assess
binge eating behaviors (e.g., amount of food consumed)
as well as associated cognitions and emotions (e.g., guilt,
shame). The BES was devised specifically for use with
obese individuals (Gormally et al., 1982). Scores on the
 CBT for Bariatric Surgery Patients
BES range from 0 to 46, and moderate and severe levels of
binge eating correspond to cutoff scores of 18 and 27.
Emotional Eating Scale (EES; Arnow, Kenardy, & Agras, 1995)
The EES is a 25-item self-report measure that assesses
the tendency to cope with negative affect by eating.
Respondents are presented with 25 emotions and are
asked to rate the strength of their urge to eat on a scale
from 0 (no desire to eat) to 4 (an overwhelming urge to eat)
when experiencing each of the emotions. The EES
consists of three subscales reflecting anger/frustration,
anxiety, and depression.
Patient Health Questionnaire (PHQ-9; Spitzer et al., 1999)
The PHQ-9 is a 9-item self-report measure of depres-
sion severity. Respondents are asked to rate the frequency
with which they have experienced depressive symptoms
over the last 2 weeks on a scale ranging from 0 (not at all)
to 9 (nearly every day). Scores on the PHQ-9 can range
from 0 to 27, and mild, moderate, moderately severe, and
severe levels of depressive symptoms correspond to cutoff
scores of 5, 10, 15, and 20, respectively.
Statistical Analysis
Paired-samples t-tests were conducted to examine
changes in questionnaire scores from pretreatment to
posttreatment. The pilot study sample size of eight likely
provides insufficient power to detect statistically signifi-
cant changes. However, changes in questionnaire scores,
trends for statistical significance, and Cohen's d effect
sizes are reported below. A p b 0.05 was determined to be
statistically significant. Cohen's d effect sizes of 0.2, 0.5,
and 0.8 correspond to small, medium, and large effects,
respectively.
Pilot Study Results
Pilot study participants had a mean age of 40.0 years
(range 24 to 54 years). The sample was predominantly
female (n = 7; 87.5%), which is typical among bariatric
surgery programs (Arkinson, Ji, Fallah, Perez, & Dawson,
2010). All pilot study participants completed all six
sessions of the CBT protocol over a maximum of
8 weeks. Pilot study participant characteristics and their
pre- and post-CBT questionnaire scores are presented in
Table 2.
Eating Pathology
Both participants who received CBT prior to surgery
reported engaging in eating binges prior to starting CBT,
in which they ate an unusually large amount of food given
the circumstances and experienced a loss of control over
eating. Following CBT, both participants reported re-
ductions in their binge eating according to the EDE-Q
(Patient A reduced from four to one binge days in the past
539
week and Patient B reduced from seven to four binge days
in the past week). Not surprisingly given the reduced
gastric pouch with Roux-en-Y gastric bypass surgery, all
but one participant who received CBT following bariatric
surgery reported no eating binges prior to or following
CBT. Patient G reported one binge day in the week prior
to starting CBT and the same frequency was reported
following CBT. Both postoperative patients who endorsed
experiencing a loss of control over eating (without eating
objectively large amounts of food) reduced the number of
episodes of loss of control following CBT.
The BES Total Score improved from pre-CBT (M =
22.6, SD = 11.2) to post-CBT (M = 15.3, SD = 12.9), t(7) =
4.09, p = 0.005, d = 0.60. The pre-CBT mean score on the
BES falls within the moderate binge eating range, whereas
the post-CBT score falls within the non-binge-eating
range. According to the BES, all pilot study participants
reported reductions in binge eating severity from pre- to
post-CBT. However, despite overall improvements in
binge eating, three participants (Patients B, D, and H)
reported binge eating symptoms in the moderate range of
severity or greater even following CBT. Recall that the
BES assesses binge eating behaviors and associated
cognitions and emotions; thus, high scores may not
reflect binge eating behavior per se. In addition, the BES
may capture both objective and subjective binges.
Urges to Overeat Due to Negative Emotions
The EES Total Score showed a trend toward improve-
ment from pre-CBT (M = 66.8, SD = 25.8) to post-CBT (M =
47.6, SD = 20.9), t(7) = 2.07, p = 0.08, d = 0.82. Scores on the
Anger scale improved from 29.0 (SD = 12.9) to 21.0 (SD =
8.9), t(7) = 1.85, p = 0.11, d = 0.72. Scores on the Anxiety
scale improved from 22.9 (SD = 11.0) to 16.3 (SD = 9.1),
t(7) = 2.04, p = 0.08, d = 0.65. Scores on the Depression scale
improved from 14.9 (SD = 5.4) to 10.4 (SD = 4.5), t(7) =
1.89, p = 0.10, d = 0.91. According to the EES, all but two
participants (Patients B and C) reported that their urges
to eat in response to negative emotions reduced from pre-
to post-CBT.
Depression Symptomatology
Scores on the PHQ-9 showed a trend toward improve-
ment from pre-CBT (M = 6.6, SD = 6.1) to post-CBT (M =
4.3, SD = 5.6), t(7) = 2.13, p = 0.07, d = 0.31. The pre-CBT
mean score on the PHQ-9 falls within the mild depression
range, whereas the post-CBT score falls within the
nondepressed range. All but two participants (Patients B
and F) reported reductions in depressive symptoms from
pre- to post-CBT.
All pilot study participants provided positive qualitative
feedback regarding their experience with CBT, regardless of
the timing of the intervention (preoperative, postoperative)
and mode of delivery (in person, telephone). The most
common point of feedback given by participants (even those
 540
Table 2
Demographic and Clinical Variables

Participants
Variables A B C D E F G H
Demographics
Age 28 52 26 45 44 54 24 47
Gender F F F F F F F M
Diagnoses MDD (partial MDD MDD (full None None None MDD (partial BED
remission) BED remission) remission)
SP PTSD BED (past) BED
PDA
SP

Cassin et al.
BN (past)
CBT Delivery
Timing Pre-surgery Pre-surgery Post-surgery Post-surgery Post-surgery Post-surgery Post-surgery Post-surgery
Method In Person In Person In Person Telephone Telephone In Person In Person In Person
Measures pre post pre post pre post pre post pre post pre post pre post pre post
EDE-Q Large amount 4 1 12 4 0 0 0 0 0 0 0 0 2 1 0 0
of food?
EDE-Q Loss of control 4 1 12 4 0 0 4 1 0 0 0 0 1 1 3 0
EDE-Q Binge days 4 1 7 4 0 0 0 0 0 0 0 0 1 1 0 0
BES Total 24 15 36 35 4 2 32 23 13 6 15 1 24 10 33 30
EES Total 79 50 61 60 37 47 99 25 92 63 32 25 48 28 86 83
EES Anger 36 22 32 27 11 22 43 11 41 29 14 11 17 12 38 34
EES Anxiety 24 15 13 15 19 15 36 9 32 22 10 9 12 9 37 36
EES Depression 19 13 16 18 7 10 20 5 19 12 8 5 19 7 11 13
PHQ-9 Total 17 11 15 15 2 1 6 0 5 1 0 3 5 1 3 2
Note. EDE-Q = Eating Disorder Examination-Questionnaire (assesses number of large eating episodes, number of episodes of loss of control over eating, and number of days with eating
binges in past 7 days); BES = Binge Eating Scale; EES = Emotional Eating Scale (assesses urges to overeat in response to anger, anxiety, and depression); PHQ-9 = Patient Health
Questionnaire-9 (assesses severity of depressive symptoms). Higher scores on the EDE-Q, BES, EES, and PHQ-9 indicate greater pathology. MDD = major depressive disorder; BED =
binge eating disorder; BN = bulimia nervosa; PTSD = posttraumatic stress disorder; SP = social phobia; PDA = panic disorder with agoraphobia.
 CBT for Bariatric Surgery Patients
who did not demonstrate improvements on the outcome
measures following treatment) was that they wished they
could continue receiving CBT beyond the six-session
intervention. Participants commented that they gained
insight into the factors contributing to their current eating
patterns and the behavioral changes that were required prior
to and following bariatric surgery. They also highlighted the
importance of maintaining food records in order to identify
maladaptive eating patterns, and of replacing overeating
with other pleasurable activities. Both individuals who
received CBT sessions by telephone commented on the
convenience of the telephone sessions (i.e., “receiving
therapy in my own home at a time that fits with my
schedule”; avoiding downtown traffic and the costs of fuel
and parking).
Discussion
This paper describes a six-session individual CBT
intervention for bariatric surgery patients, and a pilot
study examining the feasibility and effectiveness of the
intervention in improving eating pathology and psychoso-
cial functioning (e.g., depression). We sought to deliver a
CBT intervention that would be suitable for a wide variety of
preoperative and postoperative bariatric surgery patients
and could be delivered either in person or by telephone.
Many bariatric surgery patients feel left to cope without
tools following bariatric surgery, particularly if they had a
history of binge eating or overeating to cope with negative
emotions. Thus, the CBT intervention focused on teaching
coping skills that could be helpful prior to and/or following
bariatric surgery, such as scheduling healthy meals and
snacks at regular time intervals, planning pleasurable
alternative activities to overeating, planning for difficult
eating situations, and reducing vulnerability to emotional
overeating by solving problems and challenging negative,
counterproductive thoughts.
The preliminary results of this pilot study are
promising. Although the sample size was too small for
most of the treatment effects to be statistically significant,
improvements were reported on all outcome measures,
including binge eating frequency, binge eating symptom-
atology (i.e., cognitions, emotions, behaviors), urges to
overeat in response to negative emotions (e.g., anger/
frustration, anxiety, depression), and depression symp-
tomatology. Of the eight pilot study participants, five
(Patients A, D, E, F, and G) made notable improvements
on all outcome measures, one (Patient B) improved binge
eating frequency but did not show improvements on the
other outcome measures, and two (Patients C and H)
showed little improvement on the outcome measures.
Three participants (Patients B, C, and H) reported little, if
any, change on the EES despite a reduction in or absence
of eating binges. The EES assesses the urge to overeat in
541
response to negative emotions; thus, this finding suggests
that patients may continue to experience the urge to
overeat but do not necessarily act on this urge. Of note, all
three of these patients had a past or current diagnosis of
binge eating disorder during their baseline assessment.
On some of the other outcome variables (i.e., binge
eating frequency, depression scores on the PHQ-9), the
lack of improvement could have been attributed to low
baseline scores.
This small pilot study also provides some preliminary
evidence that the CBT protocol is feasible to deliver by
telephone. The two participants who received CBT by
telephone were e-mailed the handouts 1 week in advance,
and were asked to read the chapter prior to the next session
and to have a printed copy in front of them during the CBT
session so they could follow along with the CBT therapist.
They completed worksheets for homework and e-mailed
the worksheets to the CBT therapist prior to next session.
Both individuals who received CBT by telephone were
compliant with treatment, and both reported improve-
ments in eating pathology over the course of CBT.
Some participants raised specific medical and nutri-
tional questions during CBT, such as questions about
diabetes (e.g., blood glucose results, insulin management)
and dietary requirements (e.g., appropriate caloric con-
sumption). In these cases, the CBT therapists consulted
with staff nurses and dieticians and communicated the
information back to the patient. Patients were also able to
schedule appointments with staff nurses and dieticians as
part of the naturalistic clinical service. In the future, it might
prove beneficial to more formally incorporate interdisci-
plinary consults or education into the CBT protocol.
Limitations and Future Research
One potential limitation of this pilot study is the
reliance on self-report measures of eating pathology and
depressive symptomatology. The EDE-Q has been shown
to perform as well as the EDE interview in assessing
objective eating binges in bariatric surgery candidates
(Kalarchian, Wilson, Brolin, & Bradley, 2000). However, it
is difficult to assess eating binges following bariatric
surgery because patients are unable to eat objectively
large amounts of food, yet 39% of patients report
experiencing loss of control over their eating 24 months
postsurgery (White et al., 2010). The remaining study
limitations are due primarily to the fact that this was a
small pilot study. For example, males, preoperative
patients, and individuals who received CBT by telephone
are underrepresented in the study, and future research
would benefit from including more males, and including
an equal proportion of pre- and postoperative patients
and an equal proportion of individuals who receive CBT
in person and by telephone. In addition, a control group
542 Cassin et al.
was not included for comparison purposes, and patients
were not randomly selected from the pool of all patients
receiving services in the TWH-BSP. They were selected for
the pilot study because staff in the program felt that their
eating behaviors and/or negative thoughts made them
suitable candidates for CBT, and it is uncertain if our
results would generalize to larger samples of bariatric
surgery patients as a result of this selection bias. Finally,
weight loss outcomes were not assessed so the impact of
the CBT intervention on weight loss is currently unknown.
The next step to build upon the results of this pilot study
is to conduct a randomized controlled trial in which CBT is
compared to treatment as usual (i.e., routine clinic visits).
All eligible patients from the Bariatric Surgery Program
would be randomized to treatment as usual or to one of
four CBT groups (preoperative or postoperative CBT,
delivered in person or by telephone). This methodology
would permit an examination of whether CBT is more
efficacious than treatment as usual, whether it is more
efficacious when delivered preoperatively or postoperative-
ly, and whether CBT delivered by telephone has compara-
ble efficacy to CBT delivered in person. It would also be
important to include a wide range of outcome measures,
including quality of life and weight loss. In addition, a large
sample size would permit an examination of variables that
predict positive treatment response. Given that bariatric
surgery is on the rise, it is critically important to examine
brief psychological interventions that have the potential to
improve surgical outcome and psychosocial functioning in
order to maintain long-term lifestyle changes.
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The authors would like to thank the experts who provided
recommendations for client workbooks and clinician manuals
potentially suitable for bariatric surgery patients.
Disclosures: Dr. Sanjeev Sockalingam has received a speaker honorarium
from Lundbeck Canada, Roche Canada, Covidien Canada, and Pfizer
Canada. Dr. Sagar V. Parikh has served as a consultant and also received
honoraria from AstraZeneca Canada, Bristol-Myers-Squibb Canada, Eli
Lilly Canada, Lundbeck, and Pfizer; has received grants for research
and/or education projects from Apotex, AstraZeneca Canada, Bristol-
Myers-Squibb Canada, Eli Lilly Canada, Lundbeck, Novartis, Pfizer, and
Servier; and holds shares in Mensante corporation. No other co-authors
have disclosures to report.
Address correspondence to Stephanie E. Cassin, Department of
Psychology, Ryerson University, 350 Victoria St., Toronto, ON, M5B
2K3; e-mail: stephanie.cassin@psych.ryerson.ca.
Received: August 6, 2012
Accepted: October 31, 2012
Available online 10 December 2012