Intimate Saboteurs

There’s no doubt that you will feel better both physically and emotionally as you lose weight. We hope that all of your family and friends will share your enthusiasm and support you in your efforts. However, we want you to know that sometimes, someone emotionally close might have a surprisingly difficult time accepting such a dramatic weight loss…and may become an “Intimate Saboteur.”

We hope you’ll find this article, reproduced from Obesity Surgery, both interesting and helpful in understanding this complex situation—particularly the patient scenarios and the discussion following.

Allied Health Sciences
Gaye Andrews PhD, MFCC
LiteLife Counselor & Patient Educator, Saint Luke Medical Center,
Pasadena, California, USA

Author: Living a Lighter Lifestyle: A Guide to Successful Weight Loss and Maintenance Following Gastroplasty or Gastric Bypass

Background

The bariatric patient exists in dynamic relationship with family members and friends who have considerable influence upon the patient and his or her surgical outcome. When family members and friends behave as intimate saboteurs, they attempt to hamper, hurt, or subvert the bariatric patient’s goal of achieving and maintaining a healthy body weight. Successful or not, intimate saboteurs provide significant treatment challenges for the patient and the treatment team.

Methods and Patients
Patient profiles provide examples of intimate sabotage. The psychological construct of Family Systems Theory is used as a plausible explanation for the sabotage of friends and family.

Conclusions
Multidisciplinary professionals treating the bariatric patient must be aware of the critical influence of intimate saboteurs and the tactics they use to sabotage. Treatment guidelines recommended by Family Systems Theory are presented as strategies to mitigate the influence of intimate saboteurs.

Key Words: Family Systems Theory, gastric bypass, Gastroplasty, morbid obesity, obesity surgery, patient profiles, sabotage, saboteurs, treatment.

INTRODUCTION

Sabotage is a concept with which we are all familiar. In Webster’s Ninth New Collegiate Dictionary, the word is given three definitions.

The first two are:

1. destruction of an employer’s property . . . . or the hindering of manufacturing by discontented workers; 2. destructive or obstructive action carried on by a civilian or enemy agent designed to hinder a nation’s war effort”.* These kinds of sabotage are the sensational grist of spy novels, movie thrillers, and news headlines.

The third definition of sabotage is “3a. an act or process tending to hamper or hurt; b. deliberate subversion.” * Though not sensational enough for the media, this kind of sabotage often adds unwanted drama to every-day living.

For 10 years I have been associated with the LiteLife program, participating in the multidisciplinary treatment of obesity surgery patients at St. Luke Medical Center in Pasadena, California. My work has introduced me to many saboteurs who try to hamper, hurt, or subvert the bariatric patient’s goal of achieving a healthier body weight. The saboteurs are patient intimates: friends, spouses, family members. Sometimes intimate saboteurs do not succeed in sabotaging a patient’s weight loss; all too often they do. Successful or not, their sabotage is always emotionally hurtful and provides numerous treatment challenges.

The purpose of this paper is to present examples of intimate saboteurs and to discuss how and why they sabotage. Treatment guidelines and recommendations designed to mitigate the influence of intimate saboteurs will also be given. The five patient profiles presented are factual, although the names and some of the circumstances have been changed to preserve patient confidentiality.

METHODS

Patient 1
Like most bariatric patients, Ann thought carefully about having gastroplasty for severe obesity. Ultimately, her decision was based upon the fact that she was a single mother. As the only family available to raise her children, Ann wanted to insure she would be healthy enough to do it. Ann had discussed her decision with her best friend, Marge, also an overweight single mother, and believed she had her support.

While in the hospital awaiting surgery, Ann received a call from Marge. During the conversation Marge remarked, “I am calling to say goodbye.” Ann laughed and assured Marge that surgery would not be her demise. Ann expected Marge to visit her while she recuperated in the hospital. Marge did not visit. Concerned about her friend, Ann called Marge only to discover that she had been serious about saying goodbye. Marge insisted that she could not be Ann’s friend if Ann were slimmer than she was. Ann’s decision to lose weight meant the end of the friendship.

Following surgery, Ann quickly lost 18 kg, but grieved deeply over the loss of her friend. Compelled by her grief, Ann began to consume candy bars blended into ice cream to stop her weight loss, and hopefully, regain her friendship with Marge.

Patient 2
’s appearance and deliberately withheld all affection from her. Cynthia hoped successful weight loss would improve her marriage.

Following gastroplasty, Cynthia lost 41 kg and looked better than she had in years. Her new appearance did get a reaction from Ralph, but not the one for which she had hoped. Ralph responded to Cynthia’s new body image with jealousy. He incessantly questioned Cynthia about her activities and accused her of flirtations and affairs. He began to tempt Cynthia to eat. One temptation used was coming to bed to watch the late news with a half-gallon of ice cream (one of Cynthia’s favorite foods) and two spoons. It did not take long for Ralph’s jealousy to overwhelm her, and she gave in to his pressure to eat. As Cynthia ate, her weight increased and Ralph’s jealousy decreased. Eventually, Cynthia regained all of the weight she had lost.

Patient 3
Elizabeth was 56 year old. She and her husband, Bob, had been married for over 30 years and had 10 children. Elizabeth could not walk due to a painful arthritic condition exacerbated by severe obesity. Devoted to Elizabeth, Bob tried to ease her life by remodeling their home to be wheelchair accessible, and by providing her with a sophisticated computer so that she could pay bills, shop, and correspond with friends while confined at home.

Concerned about her health, Elizabeth’s physician recommended gastroplasty. He suggested that reduced weight might improve her condition and enable her to walk. A few months after surgery, Elizabeth had lost 34 kg and was walking. She was eager to become active in the world outside her home. Bob was distressed by Elizabeth’s potential new freedom. He was afraid that her ability to be independent meant that she did not need him anymore. He was concerned that Elizabeth would walk away from the marriage and that he would be alone. In response to his fear, Bob began an affair and left Elizabeth to live with the other woman.

Elizabeth had no intention of having her marriage end. She persuaded Bob to return home. Together they are working to establish a new balance of interdependence in their relationship.

Patient 4
When Jennifer enrolled in the LiteLife program, she described herself as a homemaker with a terrific marriage and family. Her only discomfort was her severe obesity. Jennifer felt her weight inhibited her emotionally and limited her social interactions and career opportunities. A gifted artist, Jennifer hoped weight loss following gastric bypass would improve her self-esteem, and give her the confidence to study art and make it her career.

Jennifer was a model patient. She followed her nutritional and exercise program faithfully. In less than one year, she achieved her goal weight. Her self-esteem and confidence did improve and she felt ready to enroll in art school. When Jennifer told her husband, Sam about her desire to be an artist, he forbid her to pursue a career of her own. For support, Sam enlisted his pastor who admonished Jennifer that her religious faith required that she submit to her husband’s authority.

Jennifer attended support groups and read self-help books to encourage her weight loss. She believed that she could be a good wife, mother, and homemaker while she pursued her art. She did not feel her career goal was a threat to Sam’s position of authority in the home or a denial of her faith. Jennifer struggled to negotiate a mutually satisfactory resolution to the situation. Sam’s response to Jennifer’s efforts was anger that rapidly escalated to spousal abuse. When she had been hit one too many times, Jennifer divorced Sam. She has maintained her goal weight, cares for her children, and attends art classes. Jennifer is now engaged to someone who encourages her in her marriage, family, and career goals.

Patient 5
Susan came to the LiteLife program because her physician advised her that her obesity was contributing to her infertility. Susan hated being obese and she desperately wanted a child. With the help of gastroplasty, Susan lost weight, conceived, and gave birth to a beautiful baby girl. A dream had come true for Susan and her husband, Mark.

After the birth of her daughter, Mark, along with his and Susan’s parents, began a campaign for Susan to reverse her surgery. All obese, they were uncomfortable because Susan no longer ate and looked like them. They argued that Susan had accomplished her goal of having a child; therefore, she had no reason to preserve her weight loss.

Susan enjoyed her slimmer, healthier body and resisted the family pressure for a number of years. Eventually, the family wore her down. She had her surgery reversed and regained the weight which she had previously lost.

DISCUSSION

These profiles are only a few of the many examples of our bariatric patients’ experience with intimate saboteurs. How common is this experience? Very common, according to interviews and national surveys conducted by Barbara Jacobson and Richard Stuart reported in their book Weight, Sex and Marriage. ** More than 24,000 overweight women reported to Jacobson and Stuart that losing weight created problems in their relationships that weight regain would resolve. Anecdotal reports to LiteLife treatment professionals, suggest that as much as 30% of our patient population experience some relationship distress following bariatric surgery.

One answer as to why those nearest and dearest to the bariatric surgery patient will attempt to sabotage them and why the patient will allow it is found in the psychological construct of Family Systems Theory. Close friends and the significant others of those living together without benefit of marriage are included in the Family Systems approach.

Family Systems Therapy was developed in the 1950’s. Family Systems therapists believe that the family is the most powerful emotional system to which a person ever belongs. Within the family, each person has a place of power and attachment that is shaped or determined by the needs of the given family system. Every member of the family works to maintain their position in order to protect the cohesiveness of the system.

From the perspective of Family Systems Theory, change in one member of a family upsets the balance of power and attachment important to the system. To maintain balance, the other family members must either change or they must resist the change, in the hopes of re-establishing the former dynamic of power and attachment. If the other members of the system do not change with the individual, or if they are unsuccessful in resisting the change, the system will break down. According to Dr. M. Scott Peck and his wife and co-therapist, Lily, marriages tend to be especially vulnerable to breakdown when one partner changes and the other does not. ***

The bariatric surgery patient is one who has chosen change; often significant, multi-faceted change. Successful patients experience change in their weight, health, self-esteem, confidence, and personality expression, as well as participation in social, educational and career opportunities. Most patients feel enriched by the change. When friends, spouses, and family members experience the change as positive and adjust to it, relationships are often enhanced. Everyone feels they benefit from the change that the patient initiated.

When friends, spouses, and family members are disturbed or threatened by the change, when they feel they will lose their position of power or attachment because of it, they will resist the change by trying to sabotage it. Dr. Susan Forward calls intimate saboteurs “emotional black-mailers” and describes their tactics of sabotage as FOG: fear, obligation, and guilt. FOG is a powerful form of manipulation that directly or indirectly threatens punishment. The purpose of FOG is to signal: if you do not do what I want, you will suffer. **** The greatest suffering for most people involves the loss of the relationship. Confronted with these tactics, the bariatric patient faces a terrible dilemma: to pursue change and jeopardize the relationship, or sacrifice change to protect it.

There are those who treat the bariatric patient who believe that there ought not to be a dilemma. They feel that the health and welfare of the individual bariatric patient supersedes any relationship. If a relationship cannot adjust, then let it end. However, that is to ignore the powerful psychological, social, economic, ethical and religious importance of relationships. Furthermore, just as patients are the ones to decide whether to have bariatric surgery or not, they are the ones to decide whether to stay in a given relationship.

As professionals, rather than discount the dilemma, I suggest the importance of accepting and dealing with it. At St. Luke Medical Center, we have used Family Systems treatment guidelines to develop procedures designed to mitigate sabotage by overly including the potential saboteur in the treatment process. How do we do this? First, we invite close friends, spouses, and family members to participate in a patient’s treatment program by attending pre-surgical consultations as well as pre-and post-surgical educational sessions. In all of these meetings, relationship benefits and stressors associated with bariatric surgery are discussed and strategies for dealing with the stressors are collectively negotiated.

Second, a psychosocial interview is conducted with every patient. During the interview, the patient is asked in detail about marital, family and friendship relationships. Inquiry is made regarding satisfaction of the relationships, the presence of any problems, and the attitudes of those close to them about bariatric surgery and the lifestyle changes that often follow. Responses to the questions alert us to potential sabotage, and strategies to counteract it are discussed with the patient.

Third, support programs are available to patients and those close to them when relationship distress and/or sabotage does occur. The support programs include access to self-help books, videos, and relationship education sessions. Referral to individual, couple, and family psychotherapy, is provided as needed.

The goal of these treatment procedures is to inhibit sabotage by dealing with it candidly and by providing support for the changing friendship, marital, or family system. Of course, the bariatric patient and his or her success is, and will always be, our primary focus. To facilitate the patient’s success, however, we have learned not to ignore the influence that friends, spouses, and family members have upon surgical outcome. A successful surgical outcome often requires treatment of the patient and his or her friends, spouse, and family members – those who could potentially be intimate saboteurs.

REFERENCES

* Merriman-Webster, Webster’s Ninth New Collegiate Dictionary, Springfield, MA: Merriman-Webster, Inc., 1984, 1034.

** Stuart RB, Jacobson B. Weight, Sex and Marriage. New York: Norton and Company, 1987: 3-8.

*** Peck MS. The Road Less Traveled and Beyond. New York: Simon and Schuster, 1997: 169-72.

**** Forward S. Emotional Blackmail. New York: Harper Collins Publishers, 1997: 39-59.

Presented at the Allied Health Sciences session, 14th Annual Meeting of the American Society for Bariatric Surgery. 4th June, 1997, Chicago, USA.

Correspondence to:
Gaye Andrews, PhD, MFCC.
490 Sierra Keys Drive,
Sierra Madre, CA 91024, USA.

Tel: (818) 355-7025
Fax: (818) 798-3450
Pt.Pkt.saboteurs.article.02-01

Reproduced with permission from OBESITY SURGERY, 1997: 7, 445, 448, Gaye Andrews PhD, MFCC,
Intimate Saboteurs