The Monk and the Mensch

I first heard about Phil Stutz and Barry Michels on NPR. This was shortly after the publication of a profile of Barry in The New Yorker in 2011. You can read the article here:

http://www.newyorker.com/magazine/2011/03/21/hollywood-shadows

I related immediately to Phil's impetus for creating techniques for therapy called The Tools: the frustration therapists feel when they (we) have competently formulated the combination of genetics and experiences that have created the human in front of us and they (we) have no earthly idea how to help. I awaited their book with great hope for the future of my life and my practice.

And then in 2012 it appeared: The Tools: 5 Tools to Help You Find Courage, Creativity, and Willpower - and Inspire You to Live Life in Forward Motion. I devoured it. You can buy the book here:

https://www.amazon.com/Tools-Courage-Creativity-Willpower-Inspire/dp/0812983041/ref=sr_1_1?s=books&ie=UTF8&qid=1483821071&sr=1-1&keywords=the+tools+book

Then in 2014 I participated in a weekend seminar with Phil and Barry at the Omega Institute in Rhinebeck NY, and in 2015 and 2016 a weeklong seminar. I use at least one of the tools every day. In fact, I am using the tool called Reversal of Desire right now to keep me writing. (More later.)

You may be familiar with cognitive behavioral therapy: if you change your maladaptive thoughts and destructive behaviors, other psychological symptoms like depressed mood or binge eating will abate. This approach has always left me cold. Where's the affect, the feeling? And can something like depression really be reduced to thoughts and behaviors? I don't doubt that CBT has been effective for people, but I could never seem to present it to a patient with confidence.

The Tools integrate feelings into a model that also includes thoughts and behaviors. Key elements of the model are the True Self, the Shadow and Part X. And the entry point to change is feeling, which has always seemed to me the right place in the gears to stick your fingers if you want to stir things up.

So this essay is a brief introduction to The Tools and their creators, as well as an endorsement from me to use them. I often work with patients who struggle with weight loss, many of whom have had bariatric surgery. Tools, especially Reversal of Desire and Inner Authority, are now an indispensable part of my work with these individuals.

Phil Stutz is from NYC and he has the attitude and the accent to prove it. Phil doesn't seem impressed with anyone or anything. He doesn't get distracted from his message by the trappings of success.

Phil tells a story about an early presentation he was giving about The Tools. He was so nervous he wrote his entire presentation on note cards and proceeded to read the text off the cards. The room was dead. (I've always wondered why everyone didn't leave at the break, but they must have sensed something valuable.) Anyway, during said break, Phil had a visit from his Shadow who rallied to his aid. As you can guess, the post-break presentation was a huge hit.

Phil and Barry taught me about the Shadow, first articulated by Carl Jung, whose ideas have less traction these days and were not part of any psychology curriculum of mine. Your Shadow is every part of you that you want to ignore, deny or disown, that you are ashamed of or afraid of, that you desperately try to hide. But you know it's there in all its despicable glory.

The energy we spend keeping our Shadows hidden could, if channeled productively, solve a whole lot of problems that seem intractable. And, beyond just energy, the acceptance and integration of the bad stuff makes us whole persons. A tool called Inner Authority aims to reunite the Shadow with our everyday self, the one we think is acceptable and presentable.

I noticed just yesterday what an enormous difference this tool has made in my work as a therapist: a patient who used to terrify me is now engaged in treatment at a whole new level. I use Inner Authority before and during every session with this person.

Phil says Barry Michels has used the tools more diligently than anyone else. Barry is the polished foil to Phil's ascetic. Phil and Barry present an answer to a question I've been asked many times as a therapist: If I really want to lose weight - AND I DO - why do I keep overeating and avoiding the gym? Any of this sound familiar:

Good You: I'm going to have an orange now.
Bad You: But I really feel like having cake.
Good You: Oh, no, I shouldn't eat cake.
Bad You: Oh, just this once won't hurt. Besides, I worked out this morning.
Good You: No, I don't want the sugar train to carry me away. No cake!
Bad You: Just a little piece!

For "cake," substitute "work," "exercise," "writing," "socializing," ANYTHING. Does it ever feel you have an inner saboteur? Of course, it does, at least when it comes to anything that's important to you or that requires discipline. I admit I do not have an inner saboteur about brushing my teeth, but flossing is another matter altogether.

Phil has a name for Bad You: Part X. Part X will use EVERY trick in the book to throw you off track from EVERYTHING. Part X is a big powerful machine with a 1-word vocabulary: "NO!"

True Self: Time to get up!
Part X: I don't want to!

True Self: Time to go to work!
Part X: I don't want to!

True Self: Time to finish the blog post!
Part X: I don't want to!

The bad news is that Part X is never going away. The good news is there's a tool to help quiet it so you can act the way Good You, or your True Self, knows you want to. The Tool is called the Reversal of Desire. If (almost) everything worthwhile in life results from hard work, sacrifice and pain, why do we always shrink away from pain? Logically, we should regard pain as a sign that we are on the road to a magnificent outcome. But we don't.

Reversal of Desire trains your mind to flip your opinion of pain from undesirable to desirable. (I mean, we're not talking about the pain of a migraine headache here. Rather, it's the pain of pushing yourself out of your comfort zone.)

Phil has a saying: "Work like a bandit and live like a monk." Which I interpret to mean: Push yourself to be uncomfortably creative and don't get hung up on the outcomes. Another teacher of mine put it this way: "Don't get so carried away eating the fruit that you forget to water the tree."

Very many of my patients these days obsess over outcomes. Now, results are fine, even necessary, don't get me wrong. But they are fleeting and don't often bring the inner validation people seek. Much more important is process, the way we live every day.

For example, suppose you go to college. You go to classes, write the papers, take the tests, do everything you're supposed to do. You rack up credits and then you graduate. That's a result. The goal of getting a college degree is finished, it's finite, and no one can take it away from you. But then what?

Then . . . process. And it's all process. Here's what I struggle to communicate to my patients: There's no goal to life. There's just your life. You may accomplish some goals during the course of your life, but there's no goal to life itself. There's just living.

There used to be a saying: "He who dies with the most toys wins." I always heard it as mocking materialism but a lot of people took it seriously. I feel really sorry for them. Whenever I need some encouragement I reread the part of the book about being a consumer versus being a creator (see page 204 of The Tools).

Well, I could go on for a long time. Go read the book and start using The Tools, at the very least Reversal of Desire. Start putting Part X in its place: the back of your mind, not the front. Live the life you know you want to live.

What If You Didn't Need Emotional Eating?

Many people complain that daytime stress leads to overeating at night, usually fast food or snack food. What if you could decrease your stress at work so you didn't need to reach for unhealthful food at night? What if you took lunch hours that were really hours and snack breaks that were really breaks?

An interesting op-ed in today's New York Times explains how burnout can contribute to stress - as well as decreased satisfaction and productivity - and how we can make some specific changes to our workdays to reduce burnout. And avoid emotional eating!

Click here to read the article.

Mind Over Milkshakes: Effect of Expectation of Satiety on Ghrelin

Let's review what we know about ghrelin. Identified in 1999, ghrelin is a hormone that sends information from the stomach to the brain.

When energy intake (i.e., nutrients, calories) is low or the stomach is empty, ghrelin is produced in the stomach and transported to the brain. There it binds with receptors to produce the sensation of hunger and motivate eating.

As energy intake increases and nutrients are detected in the gastrointestinal tract, ghrelin production slows, thus signaling to the brain to reduce appetite and increase feelings of satiety. This is part of the reason we're always told to eat slowly: it takes time for ghrelin production to be modulated with food intake, and time for ghrelin communication with the brain to take place, thus giving us the feeling of being full.

The power of the study presented today:



Crum, A., Corbin, W., Brownell, K., & Salovey, P. (2011). Mind over milkshakes: Mindsets, not just nutrients, determine ghrelin response. Health Psychology, 30 (4), 424-429 DOI: 10.1037/a0023467


is its simple elegance in examining the relationship of expectations of satiety on the production of ghrelin. Does one's perception via a package label affect the biological underpinnings of appetite?

Participants were brought to the research lab on 2 occasions a week apart. They were told that they would be testing 2 new shakes being developed at the lab, that they would be asked to drink and evaluate the shakes, and that blood samples would be taken to test their bodies' reactions to high and low fat and sugar content.

However, the shakes were different only in their labels . . . the contents of the containers were identical. One label read "Indulgence: Decadence you Deserve," with 620 calories, 30 grams of fat, and 56 grams of sugar. The other label read "Sensi-Shake: Guilt Free Satisfaction," with 140 calories, 0 grams of fat, and 20 grams of sugar.

Would the labels influence the participants' evaluation of the shakes? And would the expectation of what was being consumed change the production of ghrelin?

Perhaps not surprisingly, participants rated the the perceived "healthiness" of the Sensi-Shake significantly greater than that of the Indulgence shake. Remember, the only difference between the shakes was the label.

Further, there was no difference in ratings of taste between the 2 shakes. Nor was there a significant difference in the subjective feeling of hunger. These are powerful results in themselves. The labels did not influence the participants' perception of taste or feeling of fullness.

The researchers measured ghrelin levels 3 times: before the experiment began (baseline), after seeing the label but before consuming the shake (anticipatory), and after consuming the shake (postconsumption).  When presented with the Indulgence shake, ghrelin levels rose significantly in anticipation and declined precipitously after consumption. When presented with the Sensi-Shake, ghrelin levels remained flat or rose moderately in anticipation and declined significantly after consumption.

Further statistical analysis revealed that the significant factor in these changes was the decline in ghrelin after consumption of the shake, not the anticipatory bump. And the ghrelin levels of those in the Indulgence mindset declined significantly more than the levels of those in the Sensi-Shake group.

The statistical power of the study is enhanced by the use of the same people on 2 occasions to consume the shakes. This reduces the variability between the 2 conditions and increases the statistical power of the analyses. For example, baseline ghrelin levels are likely to be very similar in each person from week to week.

In addition, there was a 1-week interval between consuming the shake in the Indulgence mindset and the one in the Sensi-Shake mindset. This interval reduces the chance that the participants would remember the first shake and directly compare the experience of the shakes.

The erroneous nutritional content of the label had a significant effect on the ghrelin response. So what of nutrition labels we encounter every day? The authors make a worrisome conclusion:

"A product may be labeled 'low-fat' (because it is lower in fat than a full fat option) but still be a high-fat food. A food product might be a good source of fiber but still have a sugar content that is exorbitantly high. This juxtaposition of unhealthy nutrients with healthy proclamations may be especially dangerous. Not only is the product itself unhealthy, but the mindset of sensibility might correspond to an inadequate suppression of ghrelin, regardless of the actual nutrient makeup."

The mind and the body . . . intimate partners at the most basic biochemical level.

Compassion for Weight Loss Struggles

Today Tara Parker-Pope answered questions about her article that I blogged about last time. Here's the link:

Weight Loss Struggle Q & A

She stresses, as I did, compassion over complacency, wisdom over guilt.

Why We Struggle to Maintain Weight Loss

Tara Parker-Pope of The New York Times has written an excellent summary of research on set point theory, that is, the body's tendency to defend a higher weight after weight loss. And some of us may just have to work harder to maintain weight loss because of other genetic factors.

This research can be used as an excuse for weight regain - "What's the use?" or "My genes made me do it" - or as information that can help us forgive ourselves for sometimes falling short of our goals. Of course, I recommend it as a source of compassion, not an excuse for poor eating habits.

Tara Parker-Pope's article

The research also supports the idea that gastric bypass surgery resets the set point that the body will defend going forward. Surgery is not a simple engineering change. Rather, it starts a complex biochemical process that supports weight loss until the new set point is reached.

Does Preoperative Weight Loss Affect LONG-Term Postoperative Weight Loss?

Some surgical weight loss programs require that, in preparation for bariatric surgery, patients lose a certain amount of weight. This might be a fixed amount, such as 25 pounds, a percentage of total body weight, or a percentage of excess body weight. To my knowledge there are no guidelines from the American Society of Metabolic and Bariatric Surgery (ASMBS) in favor of or opposed to this requirement, as it pertains to weight loss. The ASMBS guidelines do recommend presurgical weight loss in order to reduce liver size and thus decrease surgical risk.

In the previous post, we reviewed a study looking at short-term weight loss after Roux-en-Y gastric bypass surgery. Today we will consider a study conducted at a single medical center that recommends that patients lose 10% of their total body weight before surgery. These clinician researchers state that their experience tells them that preoperative weight loss improves weight loss outcome in the long term, and their data support their expectation. However, as we'll see, there are some problems with the study that limit the validity of that claim.

Let's take a look at the results. Some number of patients were recruited for the study and their preoperative weight loss was documented. We are not told how many people initially participated in the study, only that 150 patients were available for follow-up after 3 years and 95 were available after 4 years.

Right off the bat, there is a question. How many people were unavailable after 3 or 4 years, and, more importantly, why? Were there 200 or 500 or 1,000 participants who signed on to the study in the preoperative phase? We don't know, and this means we also don't know why people were unavailable. Did they simply move away? Did they stop coming in for medical care for some other reason relevant to their weight loss? We also cannot consider how - or if - the dropout rate affects the results. Maybe the 150 patients available after 3 years and the 95 available after 4 years had some special characteristics that set them apart from the general population of gastric bypass candidates. We cannot determine this from the article.

The data clearly showed exactly what the researchers expected: a nearly linear, statistically significant correlation between the weight a patient lost before surgery the weight they had lost at 3 and 4 years out. Percentages of both total body weight and excess body weight followed this relationship.

Another problem with the study: no control group. It is a purely correlational study. This wouldn't be a problem if the researchers hadn't used the word "causation." OUCH! Remember from Intro Psych (and many other intro science courses) the 3 requirements for a true experiment: random sampling from the population, random assignment to groups, and the presence of a control group. Based on what is reported in this article, none of these conditions were met.

So, while intuitively it sounds logical that preoperative weight loss will solidify behavioral changes and ultimately influence long-term weight loss, I'm still looking for evidence that this claim can be supported. What is known is that preoperative weight loss has many other benefits for the patient, such as reduced liver size at the time of surgery (reducing the risk of converting a laparoscopic procedure to an open one), shorter operating time, and fewer surgical complications. These factors alone speak to the importance of starting weight loss as early as possible.


Alger-Mayer, S., Polimeni, J., & Malone, M. (2008). Preoperative Weight Loss as a Predictor of Long-term Success Following Roux-en-Y Gastric Bypass. Obesity Surgery, 18 (7), 772-775 DOI: 10.1007/s11695-008-9482-2

Does Preoperative Weight Loss Affect Short-Term Postoperative Weight Loss?

May is "Mental Health Month" and today is "Mental Health Month Blog Party," an initiative of the American Psychological Association's Public Education Campaign. Today, bloggers who write about mental health issues will be linked to on APA's public information web site:

http://www.yourmindyourbody.org/

So, since every bariatric surgery patient is indoctrinated with the message, "Bariatric surgery is a tool, not a panacea, and I know I have to make lifestyle changes to maintain my weight loss," I thought I would blog today about the value - or lack thereof - of losing weight before having surgery. Some bariatric surgery programs encourage, or even require, prospective patients to lose some amount of weight before having their procedure.

After all, doesn't it make good intuitive sense that solidifying some of those important behavioral changes would lead to a better outcome? Researchers at the Stanford School of Medicine asked that question and reported their results in today's article.


Eisenberg, D., Duffy, A., & Bell, R. (2010). Does Preoperative Weight Change Predict Postoperative Weight Loss after Laparoscopic Roux-en-Y Gastric Bypass in the Short Term? Journal of Obesity, 2010, 1-4 DOI: 10.1155/2010/907097


The authors question two basic assumptions in bariatric surgery research and practice - that preoperative weight loss indicates an individual's intrinsic motivation for behavior modification, and that intrinsic motivation is a valid predictor of outcome. Some institutions may deny patients bariatric surgery when those patients do not demonstrate sufficient commitment by losing weight on their own.

The researchers deserve credit for designing a very well-controlled study: all 354 study participants had laparoscopic Roux-en-Y gastric bypass surgery by the same surgeon at a single institution. All preoperative and postoperative care followed the same guidelines. Large surgical centers tend to have dedicated well-trained staff and large patient volumes. They lend themselves to this type of large prospective study.

Of the 354 patients having surgery, 256 were available for evaluation 1 year later and were included in the study. Of these patients, 125 lost weight before surgery, 104 gained weight, and 27 had no change. A statistical analysis did not find a significant correlation between weight lost (or gained) before surgery and weight lost in the first year.

Thus, the authors conclude (correctly, given their assumptions and research question) that preoperative weight loss should not be required prior to Roux-en-Y because preoperative weight change does not affect 1-year outcomes . . . assuming 1-year outcomes are all one is interested in.

But what about longer-term outcomes? It is pretty much a given that the first year post-op will result in significant weight loss. That's not where the problems set in. Continuing to lose weight and maintaining that weight loss after the first 12-24 months is where the challenges lie. And research tells us that long term success requires long-term behavior changes.

So the next question is . . . Does preoperative behavior change affect behavior change and weight loss in the long term, say 3-5 years? In other words, does the intuitive assumption that the sooner one starts behavior change the longer and stronger those new habits are likely to remain? Stay tuned.

And Happy Mental Health Month!