Xhosa Burford dissertation

The Institute for Clinical Social Work

THE ROLE OF ATTACHMENT STYLE IN WEIGHT-LOSS SURGERY OUTCOMES

A Dissertation Submitted to the Faculty of the Institute for Clinical Social Work in Partial Fulfillment For the Degree of Doctor of Philosophy

By Xhosa R. Magee-Burford Chicago, Illinois

2020

Copyright © 2020 by Xhosa R. Magee-Burford

All rights reserved

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Abstract

This study explores the lived experiences of post-weight-loss surgery patients and how attachment / relationship styles impact their post-surgical lives. Twelve post-weight-loss surgery patients completed the Experience in Close Relationships-Relationship Structures (ECR-RS) questionnaire to assess attachment patterns. These patients also participated in a semi-structured qualitative interview. I analyzed narratives using a content-analysis approach. Research data consisted of responses that illustrate the lived experience of the participants. I analyzed those responses via (a) attachment theory, (b) affect regulation theory, and (c) relational theory. My research returned five main findings: 1.

Narrative interviews did not support ECR-RS results. . . .

2.

All participants had unresolved and unconscious relational traumas that led to an insecure attachment style with both parents. . . .

3.

Participant relational trauma / insecure attachment style led to the deployment of the secondary attachment strategy, which caused mind / body disconnection. . . .

4.

The physical effects of weight-loss surgery caused mind / body reconnection. . . .

5.

Participants’ old, unresolved, and unconscious relational traumas resurfaced and threatened to disconnect the mind and body again after surgery. . . . iii

For Eric A man with a big heart

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I never lose. I either win or learn. I am fundamentally an optimist. Whether that comes from nature or nurture, I cannot say. Part of being optimistic is keeping one's head pointed toward the sun, one's feet moving forward. There were many dark moments when my faith in humanity was sorely tested, but I would not and could not give myself up to despair. That way lays defeat and death. ~Nelson Mandela

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Acknowledgments

I would like to thank my dissertation committee: Barbara Berger, Lynne Tylke, Denise Duval, Carol Ganzer, and Freda Friedman for supporting me around the world and back again; Millie Rey for her writing coaching, support, and encouragement, friends who helped with recruiting and encouragement, and my cohort that allowed a little big girl who had a learning disability be a part of them and never gave up on me to finish.

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Table of Contents

Page Abstract………………………………………......……………………………...……. iii Acknowledgments………………………………...........………...………………...….vi List of Tables…………………………………………….......………………….…… xii List of Figures………………………………………...……........………………….…xiii List of Abbreviations……………………..…………………..............……......……... xiv Chapter I.

Introduction……….......….……………….……………….…………..........……1 Overview of the Problem Formulation of the Problem

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Table of Contents--Continued Chapter II.

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Literature Review…………………………….......….…………….............…….5 Introduction Emotional Eating and Affect Regulation Attachment and Affect Regulation Theories Affect Regulation, Attachment Theories and Emotional Eating Relational Theories and Weight Loss Surgery Patients Theoretical and Conceptual Framework Research Questions Theoretical and Operational Definitions of Major Concepts Chapter

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Table of Contents—Continued

Chapter III.

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Methodology…………….........…….……….............………….….……………30 Research Strategy Study Design Research Questions Sample Selection Statement of Assumptions Statement on Protecting Human Rights Instrumentation Data Collection Quantitative Analysis Qualitative Analysis and Conclusion Formulation

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Table of Contents—Continued

Chapter IV.

Page

Results….…………………………......…………………….…………………50 Participant Demographics Participant Weight History Participant Medical History Participant Mental Health History ECR-RS Results Participant Descriptions Participant Narrative Themes They Loved Me When All about New Me Field Notes

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Table of Contents—Continued

Chapter V.

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Discussion, Implications and Conclusion…………….………………………101 Findings and Discussion Implications for Social Work Practice Limitations of the Study Conclusion

Appendices A. Flyer …………….......................……………………………………………150 B. Introduction Letter……………...........................................................……152 C. Follow-up Email Script………………………..........………………...……154 D. Consent……………...........…………………...........…………………….…156 E. Questionnaire ……………...........……………..........……………………...159 F. ECR-RS…………….........................................................…………………162 G. Dissertation Defense PowerPoint Presentation.........................................171 References………………...…...………………………...……………………. 175

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List of Tables

Table

Page 1. Demographics………………………………..………………………………51 2. Participant Weight History……………………...………………………...…52 3. Participant Medical History…………………………………….……………53 4. Participant Mental History……………………….……...…………..…….…54 5. Participant Experience of Close Relationships-Relationship Structures (ECR-RS) Results…..……………………....…………………...…….... 56 6. Participant Descriptions Results……………………...……………...………57 7. Participant Narrative Results………………………...………………………59 8. Forms of Dismissing Interviews………………….…..………..………121-122

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List of Figures

Figure

Page 1. Model of Self…………………………………..………….......……..………15 2. ECR……………………………………...……….......…….………………...17

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List of Abbreviations

AAI

Adult Attachment Interview

BED

Binge Eating Disorder

ECR-RS

Experience in Close Relationships-Relationship Structures

IWMs

Internal Working Models

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Chapter I

Introduction History of the Problem In response to obesity,1 researchers have proposed several treatments, with varying levels of success. Some of these treatments include: 1.

Behavior-modification techniques . . .

2.

Medication . . .

3.

Plastic surgery . . .

4.

Weight-loss surgery . . .

Weight-loss surgery has many benefits. It reduces the level of diabetes and heart disease in obese patients and leads to quicker weight-loss results than other methods.

Patients have reported improved health and quality of life (Kral, Sjostrom, & Sullivan, 1992; Marcus, Kalarchian, & Courcoulas, 2009).

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Obesity is characterized by excessive accumulation and storage of fat in the body.

Obesity in an adult is typically indicated by a body mass index of 30 or greater (Medical Webster). The “body mass index” (BMI) is used by the World Health Organization (WHO). The BMI is a simple calculation which measures the relationship between weight and height for individuals 20 – 74 years of age. Even though there are other scales to measure fat or weight, most medical professionals use BMI to determine if a person is considered overweight or obese.

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However, in some cases, patients regain weight because they (a) return to their old eating patterns, (b) create new unhealthy patterns, or (c) face new circumstances, such as pregnancy, divorce, or loss. The causes of obesity are complex and often not completely addressed by weight-loss surgery.

Due to a growing awareness of the link between obesity and psychological issues, many surgeons and insurance companies now require pre-surgical psychological evaluations and offer individual counseling and support groups for pre- and post-surgical patients. However, many post-surgical patients quickly opt out of individual counseling and support groups.

Researchers have started to explore the psychological factors that may cause weightloss-surgery patients to regain weight. Two of these factors are how others relate to patients and how early relationships affect patients’ lives. A variety of researchers2 have indicated a link between insecure attachments and undiagnosed binge eating disorder (BED). Chen and others (2009) examined how physical and psychological factors influence the success rates of weight-loss surgery. Even though weight-loss surgery can have dramatic results and prove beneficial, overall success depends on a multitude of variables.

Much of current research on the link between insecure attachments and undiagnosed BED has been quantitative. This research has helped identify important issues, such as reasons for overeating and trauma. If health-care providers recognize possible issues such as relational traumas and binge eating, they might be able to identify root causes and 2

These researchers include Azarbad, Corsica, Hall, and Hood, 2010; Chen et al., 2009; Kalarchian, Wilson, Brolin, and Bradley, 1996; Kalarchian et al., 2007; Kalarchian, Marcus, Wilson, Labouvie, Brolin, & LaMarca, 2002; Smith, Marcus, Lewis, & Fitzgibbon, 1998.

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suggest solutions to patients much sooner. This knowledge may help therapists (a) identify and address pre-existing contributing factors such as relational traumas and BEDs, (b) slow down a patient’s tendency to gain weight after surgery, and (c) create more successful outcomes overall. Weight-loss surgery patients might benefit from qualitative research on the connection between attachment / relationship styles and sustained success.

However, despite the success of quantitative research in health-care, the actual lived experiences of post-weight-loss surgery patients remain relatively unknown. Some researchers have proposed that qualitative studies might fill this gap. For example, Shakory and others (2015) noted that, “Examining these relationships using structured interviews such as the AAI [Adult Attachment Interview] would be beneficial” (p. 74).

This suggestion indicates possible benefits of exploring the attachment styles and experiences of adult patients after weight-loss surgery. Qualitative approaches may help us better understand the impact of attachment styles on actual patient experiences and the factors that can help sustain the patients’ progress..

Thus, a mixed-methods study that utilizes both quantitative and qualitative approaches would allow a close look at how the dynamics of actual relationships affect post-weightloss-surgery patients’ experiences.

My mixed-methods study will do the following: First, a quantitative tool, namely a questionnaire, will help identify attachment styles of participants; second, in-depth interviews will provide a qualitative element to better understand the experiences of postweight-loss surgery patients.

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Formulation of the Problem This mixed-methods narrative study intends to explore the lived experiences of postweight-loss surgery patients and how their attachment / relationship styles impact their post-surgical lives. Several researchers have begun exploration into the relationship between attachment styles and pre- and post-surgical weight-loss patients3. My research intends to build on existing literature by identifying the attachment styles of patients. I plan to accomplish this by engaging patients via in-depth, structured interviews about their own experiences. Attachment styles will be an important variable in this study.

Therefore, we need to understand whether these styles influence decisions to have weight-loss surgery. Finally, my research intends to understand how post-weight-loss surgery patients define the success or failure of the procedure.

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These researchers include Nancarrow, Hollywood, Ogden, and Hashemi, 2017; Sockalingam, Cassin, Hawa, and Okrainec, 2013; Sockalingam and Hawa, 2016; Sockalingam, Wnuk, Strimas, Hawa, and Okrainec, 2011).

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Chapter II

Literature Review Introduction When examining existing literature on the relationship between attachment and weight-loss surgery patients, a recurring theme emerges. We see a link between (a) emotional eating (especially BED), (b) affect regulation, and (c) attachment styles. Much of the literature proposes that emotional eating can result from affect regulation issues related to original insecure attachments with a primary caregiver. The researchers4 behind this literature suggest further exploration of (a) emotional eating, (b) affect regulation, and (c) attachment.

Emotional Eating and Affect Regulation For obese people, the most significant forms of emotional eating are BED and disinhibited eating. BED is defined as recurring episodes of eating significantly larger quantities of food in a shorter time period than most people would eat under similar 4

Researchers include Pace, Cacioppo, and Schimmenti, 2012; Ringer and CrittendenMckinsey, 2007; Sansone, Schumacher, Wiederman, and Routsong-Weichers, 2008; Tasca, Balfour, Richie, and Bissada, 2007; Tasca, Ritchie, and Balfour, 2011; Tasca, et al., 2009; Troisi, Massaroni, and Cuzzolaro, 2005; Wilkinson, Rowe, Bishop, and Brunstrom, 2010; Zachrisson and Skarderud, 2010).

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circumstances, with episodes marked by feelings of lack of control. Someone with BED may eat too quickly, even when not hungry (American Psychiatric Association, 2013).

Binge eating is accompanied by distress and occurs at least once per week over a threemonth period or longer.

According to the DSM5, BED may prompt feelings of (a) guilt, (b) embarrassment, and (c) disgust—as well as attempts to hide binge-eating behavior. Disinhibited eating is another form of emotional eating particularly relevant to weight-loss surgery patients.

Wilkinson and others (2010) define disinhibited eating as “. . . a propensity to engage in periodic overeating and a failure to maintain dietary restrictions,� which must be differentially diagnosed from BED (p. 1442).

The literature indicates that affect regulation deserves significant consideration. Affect regulation refers to the ability to manage emotional well-being and tolerate negative feelings. Coping with negative feelings is a learned behavior. It results from an attachment relationship with a primary caregiver attuned to the child. This attunement establishes a co-regulation between the mother and the child, which in turn allows the mother to help reduce negative feelings by soothing the child. Additionally, the attuned mother can help the child better tolerate unwanted negative feelings, by engendering feelings of safety and security, and therefore comfort. According to Fonagy and others (2001) as cited in Wallin (2007): The process of affect regulation here is one in which the infant, through a kind of "social biofeedback," comes to associate the initially involuntary expressions of her emotions with the responses of the caregiver. That is, the infant comes to "know" that her affect is responsible for evoking the caregiver's affect-mirroring responses. Thus,

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in the most desirable scenario, the infant is learning a number of very useful things: (1) that expressing her feelings can bring about positive outcomes-which generates positive feelings about the self and others; (2) that she can have an impact on otherswhich generates a dawning sense of agency or self-initiative; (3) gradually, that particular affects elicit particular reactions-which help her begin to differentiate and eventually name her feelings. (2001) Wallin describes the “social biofeedback” that occurs in the mirroring relationship between the infant and the caregiver. This mirroring can help the infant learn positive things. In a healthy process, an infant learns to express feelings in verbal and non-verbal ways. A perceived positive response prompts the infant to feel good about herself and others. By learning self-expression, the infant discovers the ability to affect her environment, which helps develop a sense of agency. The infant learns to differentiate between her own feelings and those of others. She also learns to name her feelings. If the relationship or attachment to the primary caregiver is secure, the infant learns how to regulate her affect in a healthy way.

However, if the primary caregiver is not attuned with the infant, the infant will develop a secondary attachment strategy, which will manifest as a deactivation or a hyperactivation of the relationship with the primary caregiver. According to Wallin (2007), deactivation occurs with infants classified as avoidant, and in adults with a “dismissing” state of mind. In contrast, the adaptive strategy of hyperactivation occurs with infants who are ambivalent and adults who have a preoccupied state of mind.

Disorganized infants and unresolved adults may oscillate between strategies of hyperactivation and deactivation.

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This deactivation and hyperactivation creates internal states of (a) confusion, (b) uncertainty, and (c) insecurity regarding the ability to find satisfaction. Insecurity can potentially lead the child to convert an emotional need into a somatic one, to better achieve gratification. More specifically, emotional stress may teach the child to eat, because of the good feelings associated with eating. Eating becomes a way to self-soothe, even in the absence of hunger. Essentially, in order to manage her affect, the child seeks comfort from food, instead of from the primary caregiver. Eating becomes an important means of affect regulation, and the child will eat whenever she experiences strong emotions. This can lead to overeating as means of affect regulation. Thus, binge eating results from a child’s inability to learn how to appropriately manage negative affective states without food.

Telch and Agras (1996) discuss the effects of mood on eating patterns and suggest that a negative emotional state can motivate increased food intake. The researchers state that BED subjects are more likely to suffer negative mood-induction binging. The learned behavior of binge eating responds to a low capacity for affect tolerance and regulation. If not treated or recognized, patients might struggle to maintain weight loss even after surgery. If eating remains the only means of managing feelings or affect, the patient might return to overeating and regain weight, or engage in other binge behaviors.

Weight-loss surgery may be less effective or even fail due to unresolved relational needs that result in overeating. In the past, most overeating treatments consisted of cognitive-behavioral modification programs that fulfilled personal needs via non-food substitutes. However, these programs do not explore the relational needs of the patient.

For weight-loss surgery to succeed, patients need other options (Telch & Agras, 1996).

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Evidence suggests that the success of weight-loss surgery significantly depends on addressing the underlying motivation for overeating. A variety of researchers5 found that emotional psychopathological eating contributed to the failure of weight-loss surgery.

Emotional eating can emerge or re-emerge within one to two years after weight-loss surgery. Additionally, Gianini, White, and Masheb (2013); Han and Pistole, (2014); and Wiser and Telch (1999) found a correlation between emotional psychopathological eating and affect regulation. Negative emotional states trigger emotional psychopathological or binge-eating episodes.

The literature demonstrates that binge eating may deal with negative emotional states and it may persist after weight-loss surgery.

Attachment and Affect Regulation Theories To understand the origins of negative emotional states, we benefit from examining the theories of attachment and affect regulation. Cooper and Warren (2011), Levitan and Davis (2010), and Ty and Francis (2013) link negative emotional affective states to two conditions: insecure attachment styles and emotional eating problems. In a discussion on the connection between childhood relationships with parents and childhood obesity rates, Anderson and Whitaker (2011) provide evidence that an insecure attachment, either

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Researchers include Haedt-Matt and Keel, 2011; Stein et al., 2007, Svaldi, Griepenstroh, Tuschen-Caffier, and Ehring, 2012; Whiteside et al., 2007; Zeeck, Stelzer, Linster, Joos, and Hartmann, 2011.

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avoidant or ambivalent, increases the risk of early childhood obesity in 24-month-old children.

This literature links (a) negative emotional states, (b) insecure attachment, and (c) obesity. But the question remains: What do insecure-attachment styles mean, and how are they linked to affect regulation? We can begin looking for an answer via Bowlby’s (1988) foundational theories of attachment. Bowlby devoted his career to examining the relationship between mother / child and human development. His 1988 work theorized three purposes for the relationship between a child and the primary caregiver or “the attachment figure,” as described by Mikulincer, Shaver, and Pereg (2003): First, attachment figures are targets of proximity maintenance. Humans of all ages tend to seek and enjoy proximity to their attachment figures in times of need and to experience distress upon separation from these figures. Second, attachment figures provide a physical and emotional safe haven; they facilitate distress alleviation and are a source of support and comfort. Third, attachment figures provide a secure base from which people can explore and learn about the world and develop their own capacities and personality. By accomplishing these functions, a relationship partner becomes a source of attachment security. (p. 78) Bowlby envisioned attachment as a behavioral system activated by the connection between a caregiver and a child. The system develops from proximity to the caregiver, in which the sensitive caregiver helps the child regulate. The caregiver’s behavior can provide a model for up-regulation (stimulation) or down-regulation (calming). This behavioral process has physiological consequences. It can help children regulate

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themselves and adopt healthy eating patterns (a positive consequence), whereas negative consequences include impaired appetite.

When a child learns that every time she is upset, she should eat, eating becomes a means of down-regulating her negative emotional states. If every time a child becomes distressed, the primary caregiver presents a bottle to relieve that stress, patterns develop that will lead the child to regulate affect and manage feelings through food.

Bowlby linked this behavioral system to psychodynamic theory via his recognition of internal processes. He stated that a child develops Internal Working Models (IWMs) based on interaction with caregivers. IWMs are “cognitive maps” that emerge from patterns of interactions. These IWMs shape a child’s self-representation, or how she views herself and others.

Bowlby believes that IWMs are a part of healthy development. First, the child learns how to regulate through closeness with the mother, as discussed by Palombo, Bendicsen, and Koch, (2009, p. 294). Then, the child develops an attachment style based on her perception of how well she can signal her desired response to the caregiver, and the caregiver’s ability to “read” the child. If the caregiver frequently rejects the child, the child develops an insecure attachment and a complementary IWM of the self as worthless and unloved. In contrast, a secure attachment implies the caregiver’s ready availability, which leads to the child developing an IWM of the self as worthy and lovable. Therefore, attachment styles determine IWMs. Bowlby considered attachment as resulting from a secure or insecure base. He further developed the concept of attachment with Mary Ainsworth, who discovered different categories of attachment via research with mothers and their children in Uganda and

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Baltimore (Ainsworth & Bell, 1970). Building on Bowlby’s theory, Ainsworth created the Strange Situation.

The Strange Situation provided empirical evidence of several types of infant attachment via observation of infant and parent interactions. First, Ainsworth invited mothers to play with their infants in a research environment. Researchers observed each mother and how she interacted with her child, and whether the mother could respond to the child’s needs through verbal and nonverbal communication. Then the mother left the room. Researchers observed the child’s reactions, to see whether the child could calm itself and play in the mother’s absence. Researchers also wanted to discover whether children would explore the room without their mothers, or whether they would become upset and cry.

After the mother left, a stranger entered the room. Researchers observed whether the child would play or become more anxious and look for the mother. From there, researchers observed whether the reintroduction of the mother into the room comforted the child.

This research informed several designations of attachment styles. Secure attachment indicated that the child felt safe to explore her world, knowing that she could seek solace when feeling threatened. Sustained anxiety and an inability to calm down evidenced an ambivalent attachment style. Children who did not react to the mother’s exit and stranger’s entrance indicated an avoidant attachment style; children with this latter style also did not engage with the mother while she was present.

Mary Main, a student of Ainsworth, added a fourth category: the disorganized attachment style (2000). This designation indicates that the child simultaneously received

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solace from the caregiver, but that to the child, the caregiver also represented the potential for feeling (a) threatened, (b) unattended to, and (c) unsafe. Main, Kaplan, and Cassidy (1985) udnerstood this paradox as producing disorganization and disoriented behaviors. In the disorganized attachment style, the child may freeze up and cry upon the return of the mother. These children are usually traumatized. They simultaneously depend on and fear the mother.

Main and others (1985) explored the different types of attachment styles of caregivers, hoping to help caregivers better understand their own parenting styles and possibly lead to healthier children. The researchers found that caregivers’ attachment styles generally extend from their own attachment experiences and intergenerational transmission. From this, Main and others developed the Adult Attachment Interview (AAI), which demonstrated how parents’ attachment patterns affect their children. From the findings of the AAI, Main (2000) presented four corresponding categories: 1.

“Secure and autonomous” adults can engage with an infant in a cooperative and thoughtful way, and easily recall their own attachment histories. This category correlated with the securely attached child. . . .

2.

“Dismissing” parents can have attachment histories that are (a) normal, (b) contradictory, or (c) disruptive. These parents are dismissive of attachment experiences and relationships with their children, and correspond with avoidant children (Wallin, 2007). . . .

3.

“Preoccupied” adults are distracted and incoherent. Past attachments preoccupy these parents, who can be (a) angry, (b) tearful, and (c) sad, and whose attachment style causes resistant or ambivalent attachments. . . .

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4.

“Unresolved or disorganized� parents become disorganized or disoriented when talking about their original caregivers and related traumatic attachments. They display magical thinking or disengage through long silences, and can produce a disorganized and disoriented child (Wallin, 2007). . . .

These categories allow adults to understand their attachment styles, and thereby avoid repeating dysfunctional styles with their own children. Thus, the AAI emerged as an important and helpful tool. However, the length of the AAI and the extensive special training required for its administration made the tool unwieldy for research.

In response to the AAI, researchers attempted to simplify the process of identifying attachment styles, and to explore other types of attachment. Hazan and Shaver (1987, 1990) asked participants to describe their romantic histories. From those histories, the researchers placed attachment styles into three categories: (a) avoidant, (b) secure, and (c) anxious-ambivalent (Fraley & Phillips, 2009). The involved questionnaire had fewer questions and categories than the AAI. Bartholomew and colleagues argued the necessity of four categories, and created a four-category, two-dimensional model of attachment (Bartholomew, Henderson, & Dutton, 2007). This model used Main’s four categories as a base (see Figure 1).

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Figure 1 Model of Self

Like Main, the categories include: 1.

Secure . . .

2.

Avoidant / dismissing . . .

3.

Preoccupied . . .

4.

Fearful . . .

Bartholomew used fearful instead of “unresolved” or “disorganized.” Psychodynamic concepts such as the “model of self” and “model of others” factor into the Bartholomew instrument.

Model of self refers to how a person sees herself, both positively and negatively.

Model of others refers to how a person sees others: positive and trustworthy, or negative and untrustworthy (Fraley & Phillips, 2009). The horizonal axis records positivity of the

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self-dimension, and the vertical axis records positivity of the other-dimension.

Positivity of self indicates the degree to which individuals have an internalized sense of their own self-worth, which develops from a secure attachment (Bartholomew, Henderson, & Dutton, 2007). Positivity of the other reflects expectations of others’ availability and supportiveness. The positive other indicates one’s willingness to seek support from close others. A negative other indicates one’s tendency to withdraw and maintain a safe distance within close relationships, particularly when feeling threatened.

This develops from attachments characterized as preoccupied, dismissing / avoidant, or fearful / avoidant (see Figure 2).

Following Bartholomew’s instrument, Brennan, Clark, and Shaver (1998) developed a similar instrument called the Experience in Close Relationships (ECR) interview, which examined relationships with romantic partners. Whereas Bartholomew measured how individuals rated themselves and others in attachments, Brennan focused on the degree to which an individual is avoidant or anxious. After administering the ECR, Bartholomew graphed avoidance (dismissing) scores on the y-axis and anxiety (preoccupied) scores on the x-axis. If the individual did not have a high-avoidance or high-anxiety score, researchers considered the individual to have a secure attachment (see Figure 2).

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Figure 2: (Bartholomew & Horowitz, 1991)

Building on the work of Bartholomew and Brennan, Fraley and others (2000) revised the ECR, creating the Experience in Close Relationships-Revised interview (ECR-R).

This revised interview also focused on romantic relationships. Like the ECR, the ECR-R yields scores on two subscales: Avoidance (or Discomfort with Closeness and Discomfort with Depending on Others) and Anxiety (or Fear of Rejection and Abandonment) (Fraley & Phillips, 2009). This instrument provides a structured interview to measure attachment styles. The researchers believed they had a solid definition of insecure attachment and hoped the ECR-R would produce similar certainty regarding secure attachment. However, they acknowledged that the ECR-R did not actually lead to different scores that precisely measured secure attachment. This led to the development of yet another instrument.

Fraley, Waller, and Brennan (2000) expanded the ECR-R to include questions about parents, siblings, and friends, thereby creating the Experience in Close RelationshipsRelationship Structures (ECR-RS). Fraley and Phillips described the ECR-RS as “. . . a contextual self-report measure of attachment,” and said that it is specifically “. . . designed to assess anxiety and avoidance across several distinct relationships,

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including relationships with parents, partners, and friends” (Fraley & Phillips, 2009).

The comprehensive scope of the ECR-RS interview allows for the understanding of attachment styles. In turn, a specific understanding of Attachment and Affect Regulation provides a segue to understanding the relationship between attachment and eating.

Affect Regulation, Attachment Theories, and Emotional Eating As previously noted, a person’s manner of affect regulation extends from attachment styles. Also, links exist between (a) emotional eating, (b) affect regulation, and (c) the influence of a person’s affect on eating patterns. Now we will examine the literature on the relationship between attachment style and emotional eating.

Insecure attachment results in a child’s inability to assume caregiver availability. The child must adopt methods to approximate that availability (Fonagy, 2001). Ringer and Crittenden-Mckinsey (2007) interviewed women with eating disorders to facilitate a discussion about (a) eating disorders, (b) attachment, and (c) the ways hidden family processes affect eating patterns. All female study participants suffered from anxious attachments.

Tasca, Ritchie, and Balfour (2011) and Troisi, Massaroni, and Cuzzolaro (2005) argue that people with eating disorders have attachment insecurities, and that clinicians should assess attachment functioning as a part of psychotherapeutic treatment. Tasca proposes looking at “. . . interpersonal styles, affect regulation, coherence of mind, and reflective functioning,” along with “. . . disorganized mental states related to loss or trauma” (2011, pp. 257-258).

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Sockalingam and others (2011) state that insecure attachment styles, such as avoidant and anxious attachment, are prevalent in binge-eating and pre-weight-loss surgery patients. Pace, Cacioppo, and Schimmenti (2012) found that BED patients had highly preoccupied and fearful attachments with their fathers, and that binge-eating symptoms decreased with high levels of paternal care. Tasca and others (2007) also discuss how changes to the attachment anxiety of BED patients corresponds with alleviations in depression.

Zachrisson and Skarderud (2010) discussed the relationship between other eating disorders and attachment style. Subjects with bulimia nervosa have more attachment preoccupation and subjects with anorexia nervosa have attachment dismissal. However, subjects who experience binge eating have a combination of both attachment insecurities.

Tasca and others (2009) discussed how insecure attachment styles cause a dysregulation that produces eating disorders and depression. The authors suggest close examination of attachment dimensions and affect-regulation strategies when treating eating disorders and depression.

Telch and Stice (1998) also examine the high rate of comorbidity of women with BED versus women who have not been diagnosed but who suffer from obesity. Other research shows how individuals with BED lack adaptive affect-regulation skills and use binge eating to regulate their moods. Thus, teaching adaptive emotion-regulation skills to people with BED may help them replace binge eating with healthier skills and reduce depression, which might threaten binge abstinence. (Telch & Stice, 1998, p. 774).

Wilkinson and others (2010) examine the correlation between (a) disinhibited eating, (b) attachment, and (c) body mass index (BMI). These researchers posit an association

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between disinhibited eating and attachment anxiety. They further indicate that this association can correspond with higher BMI. High scores on the attachment-anxiety scale tend to correspond with ongoing concerns about the quality of relationships with friends and family. People on this scale tend to compensate by seeking external affect regulators, including alcohol and drugs of abuse. Wilkinson states, “Our findings suggest that anxious attachment is also evident in eating behaviour, specifically in the tendency to seek comfort through overeating. Over time, this leads to a positive energy balance and an increase in BMI (2010, p. 1444).

Proposed solutions to binge eating also highlight the importance of attachment.

Kristeller and Hallett (1999) explore meditation-based intervention as a form of treatment for BED and comorbidities such as depression and anxiety. Kristeller and Hallett (1999) discuss “forgiveness meditation” as an alternative treatment for BED, stating, “. . . about half of the participants reported that a ‘forgiveness meditation’ helped them substantially resolve feelings of anger toward parents or husbands, feelings that they identified as having been common binge triggers” (p. 10).

In the studies mentioned above, attachment and affect regulation directly link to eating disorders. Our relationships with others affect eating patterns. Recent research has started to examine these correlations in a cross-sectional, quantitative approach. For example, Taube-Schiff and others (2015) investigate possible correlations between (a) emotional eating, (b) a person’s attachment style, and (c) difficulties with emotional regulation.

Shakory and others (2015) explore the relationship between (a) binge eating, (b) insecure attachment, and (c) the difficulties with emotional regulation in the bariatric (weight-loss surgery) patient. These researchers found that identifying these three

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variables in patients before surgery can improve post-surgery outcomes. Knowing the attachment style of the pre-surgery patient allows the clinician to optimize an effective post-surgical-treatment plan. The researchers noted, “Examining these relationships using structured interviews such as the AAI would be beneficial” (p. 74). This suggestion implies that attachment styles and experiences of adult patients should be explored within the context of post-weight-loss surgery.

However, these studies only focused on pre-weight-loss surgery patients. The researchers suggested additional focus on patients before and after surgery, to better understand their experiences.

Relational Theories and Weight-Loss-Surgery Patients Relational theory can help us understand relationships between (a) weight-losssurgery patients, (b) their attachment figures, and (c) the role of food in these relationships. It may also help us understand post-surgery experiences, including patient success post-surgery.

Bowlby, Ainsworth, and Main created a foundation for attachment theory. Relational theory adds to that foundation by addressing how implicit knowledge (e.g., of interactional patterns with attachment figures) can manifest in explicit behaviors (e.g., BED). If a weight-loss surgery patient suffers from BED, understanding her original attachment style and relational patterns may improve surgery outcomes.

Bowlby (1988) postulated that individuals relate to one another through internal working models (IWMs). These “cognitive maps” emerge from patterns of interactions.

IWMs shape a child’s self-representation, how she views herself and others (Palombo et

22

al., 2009). IWMs develop over time, and the individual grows up with these IWMs as implicit relational knowledge. Lyons-Ruth (1998) stated, “. . . interactional processes from birth onward give rise to a form of procedural knowledge regarding how to do things with intimate others . . . implicit relational knowing. This knowing is distinct from conscious verbalizable knowledge and . . . the dynamic unconscious� (p. 282). Whether describing IWMs or implicit relational knowledge, a child develops a sense of how to interact in relationships and cannot explicitly express these patterns.

Implicit relational knowledge could provide the basis for the triadic relationship among (a) attachment, (b) affect regulation, and (c) psychopathological eating problems.

Behaviors common to specific attachment patterns might surface in weight-loss surgery patients’ relationships with attachment figures (primary object), and food (secondary object). Thus, the child may develop IWMs that link eating or not eating with getting attention or regulating affect, especially in cases of relational trauma.

Hill (2015) explains: Relational trauma may be defined as exposure to chronic misattunement and prolonged states of dysregulation in the context of the early attachment relationship. It results in an altered development and deficient functioning of the primary affect regulating system. When seeking affect regulation, the infant encounters responses that exaggerate rather than modulate her dysregulation. The attachment figure is without the emotional capacity to sufficiently regulate the infant. The stressor is the relationship resulting in relational triggers, generalized social anxiety and impaired attachment relationships. (p. 136).

Chronic misattunement and prolonged dysregulation can lead to BED. A person may

23

use food to manage anxiety related to interactions with others. Here we can see (a) relational traumas, (b) anxiety states, and (c) impaired relationships—all as IWMs and implicit relational knowledge.

Fonagy (2001) expanded Bowlby’s theory of IWMs by linking IWMs with mental representations. According to Fonagy, “IWMs are processed implicitly and stored in nondeclarative, procedural memory, whereas mental representations are processed explicitly and stored in episodic memory” (2001, p. 263). IWMs are nonverbal memories that are ritualistic or internal. They indicate how an individual sees herself. Mental representations are external and determine how an individual sees herself in relation to others. Together, IWMs and mental representations lead to particular attachment styles and non-conscious compulsive behaviors.

In a study of the relationship between obesity and attachment, Michopoulos and others (2015) provide evidence that insecure attachment in a 24-month-old child indicates the potential risk of early childhood obesity. A person’s childhood trauma can be linked to emotional eating disturbances upon reaching adulthood. The researchers believed that their findings, . . . support a model in which obesity and related adverse health outcomes in stressand trauma-exposed populations may be directly related to self-regulatory coping strategies accompanying emotional dysregulation. . . . data suggest that emotional dysregulation is a viable therapeutic target for emotional eating in at-risk populations.

(Michopoulos et al., 2015) Impaired attachment relationships perceived as relationship trauma can cause general anxiety, in turn triggering eating as a coping mechanism to manage anxiety states.

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Thus, the physical body becomes the location where relational trauma manifests.

Even though we know where IWMs and relational traumas can appear, we still need to understand two things: how an individual develops a self, and how the sense of self or self-experience takes shape in response to (a) relational trauma, (b) IWMs, or (c) implicit relational knowledge. Wallin (2007) theorizes that the self develops through four domains of self-experience: 1. Somatic self . . .

2. Emotional self . . .

3. Representational self . . .

4. Reflective self and mindful self . . .

Within the somatic-self domain, an individual first experiences self as an infant via the physical body, and the self develops via relationships with attachment figures. Wallin (2007) explains the importance of somatic (body) experiences in the creation of self, stating that an infant’s early attachment experience can have lasting consequences because it can either lead to a positive relationship or a disconnect between body and the mind.

Potentially, [the early attachment experience] can allow bodily experience to ground, inform, and enrich the self throughout the lifespan. Alternatively, bodily experience may be denied, dissociated, or distorted—the body itself exploits or attacks for a variety of psychological purposes. Because the patient’s experience of the body is fundamental and because it takes shape in a relational context, an attachment-oriented treatment must include a focus on the somatic self (pp 62-63).

25

Wallin (2007) discusses the need to deal with somatic experience when working with a patient on attachment issues. The reverse is also true. Hill (2015) addresses how relationship trauma affects body and mind. My research proposes that somatic experience, like BED, require us to deal with relational dynamics.

The second domain, the emotional self, develops through three experiences of the attachment trilogy. First, emotions provide individuals with intuitive appraisals of themselves or of others in their environment. The infant learns her own emotions.

Second, emotions drive actions. Emotions cause an infant’s behaviors. Finally, emotions always connect to the body. The body is the vehicle that conveys our true feelings.

According to Wallin, “Bodily sensations are the first form our emotions take, and emotions are regularly expressed through the body” (2007, p. 63).

The third domain consists of the representational self that comes from IWMs. As Wallin stated, “The working models of our attachment relationships are selective, more or less representative sampling of lived relational experience” (2007, p. 64).

The final domain is the reflective self and the mindful self. This domain represents the potential to gain insight into experiences. The ability to experience the reflective self allows individuals to recognize and change their behavior. According to Tasca and others (2009), this reflective functioning or sense of self can impact the treatment of anxiety related to different attachment styles. Tasco states, “. . . treatment of patients who experience attachment anxiety may emphasize impulse regulation and reflective functioning, whereas treatment of eating disordered patients with attachment avoidance could focus on gradual exposure to affective expression and on interpersonal connectedness in the therapeutic relationship” (2009, p. 666). This suggests that treatment

26

of patients with attachment anxieties should focus on this domain.

Joyce McDougall’s mind / body concepts suggest that original attachment styles can influence later eating patterns. If an attachment style inhibits a child from separation, then independent exploration of the world is impeded, and anxiety occurs. McDougall asserts that this early anxiety state can break down what she refers to as the process of “transitory objects.”

These inanimate objects would include the bottle or blanket that an infant uses to represent the mother. With secure attachment styles, the “transitory object” provides the child with a mental representation of the mother. It provides comfort until the child learns to regulate herself. However, an insecure attachment style leads to overdependence on this “transitory object” to regulate negative emotions and it eventually becomes a coping strategy. Healthy development entails learning to self-regulate and not use transitory objects to cope. Healthy children can self-soothe, thereby dealing with negative affect without a transitory object.

According to McDougall (1989), the infant who experiences failure in this process can develop one of two solutions: a psychic solution (affect dispersal), or an addictive solution. The psychic solution separates the self from its emotions, resulting in somatization. Emotions are generated in the mind and the person separates herself from the emotions, but reenacts them through body symptoms. The addictive solution creates a profound split between the body and the mind and can result in (a) drug addiction, (b) alcoholism, and (c) binge eating, including bulimia (p 43.)

McDougall explains that addictive solutions “. . . take the form of addictive substances, addictive relationships, and perverse or addictive sexual behaviors. Addictive

27

patterns seek to disperse mental pain and psychic conflict, as the mother did when the child was an infant.”

In these patterns, external objects become “. . . magical attempts to fill the void in the inner world where a representation of a self-soothing maternal figure is lacking, and restore, if only briefly, the primitive dyadic ideal, in which all affective arousal ceases (p.

82).” This disconnects the body from the mind, which being unable to handle the affective state, reverts to non-verbal expression (p. 43). In this light we can consider binge eating as an addictive solution.

Steven Mitchell offers an additional view of relational theory and the mind / body connection via a basic relational configuration of three dimensions: (a) the self, (b) the other, or attachment figure, and (c) the space between the two, which might involve food (Mitchell & Black, 1995). Mitchell would suggest that contact with food, and others, matters more than pleasure. The process of eating may be an integral part of the person’s sense of self in relationship to others. An example of this type of dynamic can be seen in BED. Even though binge eating can be painful and unpleasant, the patient needs food to regulate her affect and maintain relationships.

Like Bowlby’s IWMs, Mitchell states that people have a tendency to repeat the same painful and unpleasant things, and that sometimes this action is unconscious (Mitchell, 1988). Throughout her lifetime, an individual can re-create (a) painful feelings, (b) selfdestructive relationships, and (c) self-sabotaging situations to perpetuate early ties to significant others (Mitchell, 1988).

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Theoretical and Conceptual Framework Based on literature findings, attachment and relational theories may provide insights into why post-weight-loss surgery patients often regain weight. The research supports the potential relationship between (a) problematic or emotional eating, (b) attachment style, mainly insecure, and (c) affective regulation. This research and related theories can offer guidance, but we still need to explore relational mechanisms. Most studies have focused on quantitative analyses without closely exploring the actual experiences of post-weightloss-surgery patients. My research intends to fill that gap.

I applied a mixed-methods approach to better understand why weight-loss surgery outcomes can be disappointing. My approach tests the relevance of existing theories and findings via patient experiences, and gains additional understanding of the experiences themselves via the following investigative lines: 1. Whether obesity was a product of the weight-loss-surgery patient’s attachment style . . .

2. What the weight-loss-surgery patients experienced . . .

3. How these patients managed their affect in the absence of their object (food) ...

4. If the loss of the object caused a dysregulation in their affect . . .

These points might help better understand post-weight-loss surgery patients from both theoretical and empirical perspectives, and develop better approaches to treatment.

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Theoretical and Operational Definitions of Major Concepts Affect regulation theory.

The study of how humans manage their emotions (Hill, 2015).

Attachment style.

How a person relates to others, based on how the person related to their original (and primary) caregiver (Ainsworth & Bell, 1970; Bowlby, 1988.)

Binge eating disorder (BED).

Recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. Someone with BED may eat too quickly, even when he or she is not hungry (Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, 2013).

Emotional eating.

The tendency to overeat in response to emotional states, both positive and negative.

Relational model.

A model or theory that claims that people’s ideas are shaped by relationships.

Relational trauma.

“Exposure to chronic misattunement and prolonged states of dysregulation in the context of the early attachment relationship” (Hill, 2015, p. 136).

Weight-loss-surgery patients.

People who will undergo or have undergone weight-loss surgery.

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Chapter III

Methodology Research Strategy The previous chapter highlighted the complicated and complex experiences of the post-weight-loss surgery patient. To examine these complexities, I conducted my study through a mixed methodology, including the collection of both quantitative and qualitative data (Tashakkori & Teddlie, 1998). I gathered all data concurrently, and combined them to look at attachment styles and stories of post-surgery recovery.

The quantitative component consisted of the Experiences of Close RelationshipsRelationship Structure (ECR-RS) questionnaire. The ECR-RS asks about participants’ attachment styles. The qualitative component consisted of interviews using open-ended questions. I employed in-depth listening to explore the post-surgery experiences of patients, instead of testing for pre-determined assumptions. In-depth listening derives from a post-positivist epistemology, which recognizes that a given reality cannot be known perfectly and that there are both subjective and objective truths.

Study Design I gathered quantitative data via the ECR-RS (Fraley, Waller, & Brennan, 2000). The

31

ECR-RS collected demographic information and asked questions about participants’ relationships with: 1.

Parents . . .

2.

Siblings . . .

3.

Friends . . .

4.

Significant others . . .

The quantitative measure identified the attachment style of patients and gave some generalizable insights into the attachment styles of people struggling with obesity. I obtained the scoring system for the ECR-RS from its developers, Fraley and colleagues (2009). I scored the surveys by hand into an Excel spreadsheet.

I gathered qualitative data via a semi-structured interview, using an open-ended protocol known as the narrative approach, developed by Lieblich, Tuval-Mashiach, and Zilber (1998). I intended the interview questions to elicit detailed narrative responses from participants about their feelings about themselves and their relationships before and after surgery. The questions allowed participants to describe their experiences in their own voices.

Using a research journal, during interviews I noted the following: 1.

Observational data about the physical and emotional state of participants . . .

2.

The flow of the interview . . .

3.

How participants told their stories . . .

4.

My subjective experiences as researcher . . .

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I invited prospective participants to meet at least twice, either in-person or via an online platform, and once over the phone for clarity of information. The interviews lasted 45 to 60 minutes. The two methodologies were (a) integrated, (b) coordinated, and (c) tabulated by hand, which allowed me to search for and possibly identify connections between attachment styles / relationships and emerging interview themes.

Research Questions Primary research question.

What are the experiences of weight-loss surgery patients and how do their attachment / relationship styles impact their post-surgical lives?

Secondary research questions.

What effect does attachment style have on the decision to have surgery? After surgery, how does the patient define success and failure of the surgery?

Sample Selection I selected research participants using non-probability purposive sampling. Purposive sampling consists of the “. . . selection of individuals / groups based on specific questions / purposes of the research in lieu of random sampling and on the basis of information available about these individuals / groups� (Tashakkori & Teddlie, 1998). I could not use random sampling because my research focuses on a specific topic and a limited pool of participant-candidates (Marshall, 1996). For this study, I interviewed 12 adults at least one year removed from weight-loss surgery.

I recruited participants by distributing flyers to people in frequent contact with post-

33

weight-loss surgery patients. These flyers provided a brief overview of the study and selection criteria and directed participants to my email address. When prospective participants contacted me, I determined their eligibility by asking qualifying questions.

Criteria for participation included the following: 1.

Participants must be one year removed from weight-loss surgery. By this point, patients have typically gone through initial post-surgery adjustments and reached their post-surgery baseline. They are ready to live their new lives. . . .

2.

Participants must be 18 years old. At this age, they can consent to research participation. Also, as adults, their attachment styles are relatively established. Attachment styles can change throughout a lifetime and vary with different people, but often an overall type of attachment exists. My study focused on participants’ current overall attachment style as an adult. ...

3.

Participants must speak English due to the researcher’s linguistic limitations. . . .

4.

Participants must be willing to participate in a semi-structured interview. . . .

5.

Statement of Assumptions I made the following assumptions when designing the study: 1.

Participants will honestly share their post-weight-loss-surgery experiences with the researcher. . . .

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2.

Every person has an attachment style. . . .

3.

The Experience in Close Relationships-Relationship Structures (ECR-RS) is an accurate measure of one’s general attachment style and is the tool closest to the Adult Attachment Interview (AAI). . . .

4.

Because one’s attachment style affects how one manages dynamics in relationships, those established relational dynamics have a major influence on the ultimate success of weight-loss surgery in the near and long term. . . .

Statement on Protecting Human Rights I obtained informed consent from each participant. Written and signed consent included: 1.

The agreement that participants voluntarily participate in the study . . .

2.

Information about the purposes of the study . . .

3.

The names of (a) the researcher, (b) the researcher’s dissertation committee members, and (c) the research readers. . . .

4.

Participant agreement to complete one attachment questionnaire with demographic questions and one in-person interview with the researcher, which would be recorded and transcribed . . .

5.

The risks of the study, including the possibility of feeling vulnerable to emotional distress in relation to discussing the experience of weight-loss surgery. I planned to respond to interviewee distress by pausing or stopping the interview and providing a referral for psychotherapy. . . .

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6.

Notice of participants’ right to withdraw from the study at any time without suffering any negative consequences . . .

7.

Procedures for ensuring confidentiality including: i. Privacy during interviews . . . ii. The researcher would not share the identities of participants with anyone . . . iii. No actual names would be used in the dissertation and other identifying information would be masked as necessary . . . iv. All recordings and transcribed data, identified only by number, would be kept on a password protected flash drive where no one other than the researcher would have access . . .

I consulted the Institute for Clinical Social Work’s Institutional Review Board to (a) assure participant safety, (b) prevent ethical violations, and (c) ensure that my study is an ethical and meaningful research project.

Instruments Experience of Close Relationship–Relationship Structures (ECR-RS) questionnaire.

Fraley, Waller, and Brennen (2000) designed the Experience of Close RelationshipsRevised (ECR-R). This ECR-R updated the original Experience of Close Relationships (ECR) questionnaire developed by Brennan, Clark, and Shaver (1998). Brennan and others designed the ECR in relation to established attachment inventories, including the Adult Attachment Inventory (AAI) (Main, Kaplan, & Cassidy, 1985). The AAI is a

36

comprehensive questionnaire, but only focuses on parental attachment. The ECR-R expanded the AAI’s focus to include all adult attachment relationships, including (a) romantic relationships, (b) parental (both mother and father) relationships, and (c) friendships (Fraley, et al., 2000).

My study used The Experience of Close Relationships-Relationship Structure (ECRRS), a contextual self-report measure of attachment. The ECR-RS assesses anxiety and avoidance across multiple distinct relationship groups, including (a) parents, (b) partners, and (c) friends (Fraley & Phillips, 2009). The ECR-RS has been gaining popularity because it is more comprehensive than other versions of the ECR. Sibley, Fischer, and Liu (2005) discuss three studies that examined the ECR-R in terms of test / retest reliability, and convergent and discriminant validity. The researchers have determined that the instrument is reliable and valid, as explained below.

Longitudinal analyses suggest that the ECR-R provided stable indicators of latent attachment during a three-week period (85 percent shared variance). Hierarchical linear modeling analyses further validated the ECR-R, suggesting that it explained between 30 percent to 40 percent of between-person variation in social-interaction diary ratings.

Specifically, these ratings addressed attachment-related emotions, as experienced during interactions with (a) romantic partners, (b) family, and (c) friends. Researchers have used the ECR-R to deliver highly reliable and precise measures of romantic attachment.

Shorter but slightly less reliable tools, such as Bartholomew and Horowitz’s relationship questionnaire, may also be viable (Sibley, Fischer, & Liu, 2005).

I found support for the applicability of ECR-RS via Wilkinson, Rowe, Bishop, and Brunstrom (2010). Even though the ECR was not normed on weight-loss surgery

37

patients, Wilkinson and others examined the correlation between (a) disinhibited eating, (b) attachment, and (c) body mass index (BMI). Regarding this work, the researchers state: . . . findings suggest that attachment anxious individuals feel less capable in disengaging from negative emotions and go on to try to soothe themselves through eating which has a negative impact on their BMI. There was less support for an explanation of the relationship between attachment anxiety and BMI based around the misperception of emotion. Taken together, the findings highlight attachment anxiety and emotion regulation strategies as key targets for interventions that aim to reduce overeating and excess body weight.� (p. 214) The 2010 Wilkinson study was purely quantitative and validates the use of an attachment-type scale in relation to food and weight. The researchers used the first version of the ECR by Brennan, Clark, and Shaver (1998).

Expanding on Wilkinson’s work, I used the ECR-RS measurement with its twodimensional scale of anxiety and avoidance, and sorted terms of attachment into four categories of attachment (see Figure 2). These four categories, as established by Fraley and others (2000), are: 1.

Secure attachment . . .

2.

Fearful attachment . . .

3.

Dismissive attachment . . .

4.

Preoccupied attachment . . .

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Figure 2 (Bartholomew K. A., 1991)

To assess attachment style, the ECR-RS asks nine questions that examine various relationships. Researchers originally wrote the nine questions to apply to every interpersonal relationship (Fraley, Heffernan, & Vicary, 2011). The nine standard ECRRS questions are: 1.

I usually discuss my problems and concerns with this person. . . .

2.

I talk things over with this person. . . .

3.

It helps to turn to this person in times of need. . . .

4.

I find it easy to depend on this person. . . .

5.

I prefer not to show this person how I feel deep down. . . .

6.

I don't feel comfortable opening up to this person. . . .

7.

I'm afraid that this person may abandon me. . . .

8.

I worry that this person won't care about me as much as I care about him or her. . . .

9.

I often worry that this person doesn't really care for me. . . .

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ECR-RS format prompts participants to rank relationship domains on a Likert scale, ranging from 1 (strongly disagree) to 7 (strongly agree). The questions ask about: 1.

Mother or mother-like figure . . .

2.

Father or father-like figure . . .

3.

Dating or marital partner . . .

4.

Closest friend . . .

The questionnaire notes that if participants are not currently in a dating or marital relationship, they should answer with respect to a former partner, or a relationship that they would like to have with someone.

I asked participants to complete a paper version of the ECR-RS after signing the consent form at the beginning of the interview process. I collected basic demographic information at the end of the ECR-RS survey by asking participants for the following: 1.

Age . . .

2.

Gender . . .

3.

Race . . .

4.

Marital status . . .

5.

Number of children . . .

6.

Educational . . .

7.

Income . . .

I used this data to further describe the sample. I did not collect identifying information, and instead assigned each questionnaire a unique identification number for tracking.

40

I obtained the scoring system from the developers of the ECR-RS, and I scored the survey by hand. I then matched that data with the semi-structured interviews (Fraley, Heffernan, & Vicary, 2011).

Semi-Structured Interview Protocol After participants completed the ECR-RS questionnaire, they engaged in a semistructured, open-ended interview designed to capture the narrative experience of their weight-loss surgery.

The interview addressed personal experiences from two points in time: before surgery and after surgery. Each interview section began with a few broad, open-ended questions designed to generate discussion. I asked several secondary questions to deepen discussion as needed. After completing the first interview, I observed a discrepancy between what the participant answered on the ECR-RS and what the participant stated in the narrative interviews. At this point, I added three more questions to the protocol: 1.

Who raised you? . . .

2.

What was your relationship with your parents growing up? . . .

3.

What role did food play in your family? . . .

Questions regarding pre-weight-loss surgery experiences.

1.

Tell me what you remember about what life was like before you decided to have weight-loss surgery and what led you to decide to have the surgery.

What were the circumstances? . . .

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2.

How did you feel and behave? What were your relationships like? . . .

Exploratory questions.

1.

How did you feel about being overweight? . . .

2.

Were you overweight as a child? . . .

3.

How old were you when you remember being told you were overweight? ...

4.

What has been the most difficult part of being overweight? . . .

5.

How did you feel your weight affected your life? Please answer this from a physical and emotional perspective. How did you feel about yourself? . . .

6.

What was your relationship like with your family before the surgery? . . .

7.

Did you ever feel like you suffered from depression or any other mental health illness? . . .

8.

Have you been diagnosed with any addictions such alcohol, drugs, food or gambling? . . .

9.

How many diets have you been on? . . .

10.

How long did you battle a weight problem? . . .

11.

How did you learn about the surgery? . . .

12.

How would you describe your relationship with food? . . .

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13.

When you were overweight, what made you anxious? Angry?

Overwhelmed? Sad? Happy? . . .

14.

Do you find that you feel the need to eat more when you are feeling anxious, angry, overwhelmed, sad or happy? . . .

15.

Were your family and friends aware that you had surgery? . . .

16.

How did your weight affect your health? . . .

17.

How did your weight affect your daily living? . . .

18.

What type of counseling did you get before having surgery? . . .

Questions regarding post-weight-loss surgery experiences.

1.

Describe your life at present: how you generally feel, what you do, the quality of your life, your relationships with others and food. . . . i.

Tell me how you have been feeling physically and emotionally since the surgery. . . .

ii.

How do you feel about yourself and your body? . . .

iii.

How has the surgery affected, if at all, your relationships with family, friends, etc.? . . .

iv.

Please describe your current relationship with food. . . .

v.

How do you deal with stressors? What are the biggest challenges?

Who are your supports? . . .

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Exploratory questions.

1.

What is it that makes you anxious? When do you get anxious? Angry?

Overwhelmed? Sad? Happy? . . .

2.

Do you find that you feel the need to eat more when you are feeling anxious, angry, overwhelmed, sad, or happy? . . .

3.

How do you see yourself now compared to before the surgery? . . .

4.

How do you see your body? . . .

5.

Do you feel good about the way your body looks? . . .

6.

How does your weight affect your self-image? . . .

7.

How is your mental health? . . .

8.

Has your relationship with your spouse, parents, friends, and others changed? . . .

9.

Do you exercise? . . .

10.

Do you miss food? What foods do you miss most? Were these comfort foods prior to your surgery? . . .

11.

How does your weight affect your health? . . .

12.

How did your weight affect your daily living? . . .

13.

Do you have any regrets about having the surgery? . . .

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14.

How did your family react to the surgery? . . .

15.

What are your thoughts about your weight before and after surgery? . . .

16.

How long was the progress? . . .

17.

Any medical problems later? . . .

18.

How do you keep your weight off? . . .

19.

How did you pay for the surgery? . . .

20.

Have you had any plastic surgery after your surgery? . . .

21.

Would you ever have the surgery again? . . .

Interviews took place at locations that participants considered (a) convenient, (b) private, and (c) comfortable (e.g., private office, participants’ home, etc.). I was the only researcher who conducted the interviews. I recorded each interview using audio and video devices, with the participant’s consent. I transcribed the audio recordings and then analyzed the transcriptions by hand.

Data Collection I invited participants who met the research criteria to take part in the study. Prior to meeting the participants, I sent them the consent form and ECR-RS to complete. In our first meeting, I reviewed the consent form to ensure that each participant fully understood the research process prior to signing the consent form. I reviewed the self-administered ECR-RS questionnaire and scored the data. I also collected demographic information and

45

then conducted a semi-structured interview, in which participants told their life stories and described their feelings about both themselves and their relationships with others during two periods in their lives: before and after weight-loss surgery.

During interviews, I recorded observational data about the following: 1.

Participants’ physical and emotional states . . .

2.

The flow of the interview . . .

3.

How participants told their stories . . .

4.

The subjective experiences of the researcher via research notes . . .

Data Analysis I conducted the study using a mixed-methods design, which included both quantitative and qualitative data analysis. The ECR-RS questionnaire is a quantitative measure that identifies attachment style by calculating responses to Likert-scale questions about relationships. Once scored, each participant’s attachment style can be determined.

Interviews produced qualitative narrative biographies related to weight-loss surgery.

These biographies offer in-depth depictions of participants’ relationships with themselves and others, both before and after surgery. Together, the data may shed light on whether attachment styles have any connection to experiences after weight-loss surgery.

According to the framework created by Tashakkori and Teddlie (1998) for analyzing data from a mixed-methodology model, parallel analysis of the two types of data provides a richer understanding of the variables and their relationship.

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Quantitative analysis.

I obtained the scoring system from the developers of the ECR-RS (Fraley et al.). I scored the survey by hand. I then matched scores from the ECR-RS with data from the semi-structured interviews.

Qualitative analysis.

I conducted qualitative analysis by using a narrative research approach. According to Lieblich, Tuval-Mashiach, and Zilber (1998), narrative research: . . . refers to any study that uses or analyzes narrative materials. The data can be collected as a story (a life story provided in an interview or a literary work) or in a different manner (field notes of an anthropologist who writes up his or her observations as a narrative or in personal letters). It can be the object of the research or a means for the study of another question. It may be used for comparison among groups, to learn about a social phenomenon or historical period, or to explore a personality.” (p. 2-3) Through this method, participants expressed their unique experiences, which elicited significant themes. The research approach delivered a rich understanding of participants’ experiences after surgery. I examined data through the lens of “life story narrative analysis” (Lieblich et al., 1998). Lieblich and others developed four methods of analyzing and interpreting narrative material:

47

1.

Holistic content . . .

2.

Holistic form . . .

3.

Categorical content . . .

4.

Categorical form . . .

My research utilized the categorical-content approach, which is based on the “content analysis model” (Lieblich, et al., p. 112). The content-analysis model focuses on “. . . the content of narratives as manifested in separate parts of the story, irrespective of the context of the complete story” (1998, p. 17). For example, using this approach helps create and define categories that lead to themes.

Categories may be very narrow, all sections in which narrators mentioned a certain political event that occurred in their lifetime, or broader, when all sections referring to political events are withdrawn from the texts for analysis.” (1998, p. 13) My research analyzed participants’ language and looked for common related themes. I wanted to uncover (a) what participants say about their experiences and relationships before and after weight-loss surgery, (b) what type of words they use, and (c) how they use description.

The 1998 work of Lieblich and others presented the categorical-content model in four main prototypical steps, beginning with the selection of the subtext. In this step, I identified and differentiated the narratives of post-surgery patients. Based on the research questions, I marked all relevant sections of the text to form subtexts. These subtext areas comprised the “content universe” as described by Lieblich and others (1998, p. 112). This step narrowed the scope of the study.

The study employed an interview format that qualifies as “directive” because it

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instructed participants to focus on their experience with weight-loss surgery and food, rather than asking the participant to provide a complete life story (Lieblich et al., 1998).

Even though the interview is directive, all obtained text can serve as content-analysis data, including wider narratives collected from the interview.

The narrative method provides researchers with access to participants’ specific experiences without challenging them. This approach increases understanding of patient interviews and can be therapeutic. My research reviewed the content from interviews (a) analytically, (b) descriptively, and (c) statistically (Lieblich, Tuval-Mashiach, & Zilber, 1998).

In the second step of the categorical-content model, researchers define content categories. I identified categories in the text by (a) extracting specific utterances, (b) coding and classifying utterances, and (c) placing utterances into different narrow or broad categories.

In the third step, the researcher sorts narrative material into content categories via principle sentences, defined by Lieblich and others as “. . . utterances that express distinct ideas about the content universe” (1998, p. 115). I processed narrative material analytically by looking at “broken-down themes.”

In the fourth step, the researcher draws conclusions and places themes from the subtext into categories. The researcher can highlight (a) words, (b) sentences, and / or (c) groups of sentences to define and demonstrate each category. This occurs by (a) counting, (b) tabulating, and (c) ordering selected parts of language, and then categorizing and subjecting them to various descriptive statistical computations, which allows the researcher to obtain quantitative measures. Alternatively, or in conjunction

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with, the researcher can use the content of each category descriptively, to formulate an overall picture of the “content universe� for the population under study.

Data from the quantitative analysis of attachment styles and demographic information can determine relationships between types of collected data. My study focused on learning if attachment styles impact patients’ post-surgery experiences and whether commonalities exist between participant demographics and their narrative stories.

Relational theory guided the process of understanding patient experiences. I integrated interaction and attachment theories to interpret possible relational features, such as enactments. The enactments in relational theory may reflect the behavior patterns of precise attachment categories.

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CHAPTER IV

Results Participant Demographics Twelve post-surgery patients (six males and six females) participated in this study. All participants were older than 18, with a mean age of 46.1 years. Six participants identified as African American, three as Caucasian, two as Latino, and one as both African American and Caucasian. Two participants were single, seven were married, one was divorced, and two were in long-term relationships. The average length of relationships with spouses and partners was 19.2 years. All participants were residents of the United States. Two lived in California, one in Florida, seven in Illinois, one in Tennessee, and one in Washington (see Table 1 for demographic data).

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Table 1: Demographics Gender Male Female Total Current Age

Participants 6 6 12 Participants

20-29 30-39

1 2

40-49 50-59 60-69 Total Ethnicity/Race

5 3 1 12 Participants

African American Caucasian Latino African American/Caucasian Total Country of Residence USA

6 3 2 1 12 Participants 12

Total

12

Marital Status Single Married Divorced Long Relationship Total Length of Relationships 1-10 years 11-20 years 21-30 years 31 + years Not in a relationship Total

Participants 2 7 1 2

States California

Participants 2

Florida Illinois Tennessee Washington Total

1 7 1 1 12

12 Participants 3 2 3 1 3 12

Participant Weight History On average, participants realized they had a weight problem when 15.75 years of age.

The average age of participants when they had surgery was 35.75 years. Participants reported an average weight loss of 131.98 pounds and their goal weight averaged 176.3 pounds. Six participants reached their goal weight after surgery, and four reported they did not. Two participants noted they are still working towards their goal weight. One participant did not have a goal weight. Eight participants reported regaining an average of 46.3 pounds.

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Participants kept weight off for an average of 8.286 years. Five participants kept off only 10 pounds or less. Five participants reported regaining no more than 10 pounds.

Four participants were male and had surgery less than six years ago. One female participant had a revision nine years after her first surgery (see Tables 2 and 2.1 for participant weight history).

Table 2: Participant Weight History Age ranges

Age when participants had surgery first time

05-14

Age when weight problem started 7

Weight loss

Participants

Goal weight

Participants

0-50

2

7

1

51-100

1

6

101-150

6

35-44

2

151-200

1

45-54

3

201-250

1

126175 176225 226275 276325 None

15-24

3

25-34

2

251-300

1

Total

12

Total

12

Total

12

12

1 2 1 1

Table 2.1: Participant Weight history

Regain Weight 201-250 151-200 101-150 11-100 0-10 Total

Participants

7 5 12

Years Kept the Weight Off 1-5 years 6-10 years 11-15 years 16-20 years Not gain weight Total

Participants 2 4 2 4 12

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Participant Medical History Eleven participants had medical issues prior to surgery. One participant had no medical issues. Four had sleep apnea and four had high blood pressure. Two participants were diabetic. One had congestive heart failure. One reported struggling with back pain (degenerative disc disease). One had plantar fasciitis (pain in the bottom of the foot due to constriction of tendons).

After surgery, two participants reported continued medical issues. Multiple participants indicated minor malnutrition issues. Two said that they developed new medical issues because they regained weight (see Table 3 for participant medical history).

Table 3: Participant Medical History Before Medical Conditions

Participants

After Medical Conditions

Participants

Congestive Heart Failure

1

Congestive Heart Failure

1

Degenerative disc disease

1

Degenerative disc disease

Diabetes

2

Diabetes

Plantar fasciitis.

1

Plantar fasciitis.

High Blood Pressure

4

High Blood Pressure

Sleep Apnea

4

Sleep Apnea

2

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Participant Mental Health History Eleven participants reported having an initial evaluation by a psychologist prior to the surgery. All participants stated that they attended support groups that discussed nutrition and behavioral issues. The participants said that they attended these support groups before and after surgery. Most did not continue after the first year. Four participants acknowledged going to counseling before or after surgery for other issues. Eight stated they had never had counseling.

Three participants reported being placed on antidepressants. Three were diagnosed with depression. One was diagnosed with Post Traumatic Stress Disorder. When asked if they had a history of eating disorders, four participants admitted binge eating but denied ever being diagnosed with the disorder. Two participants discussed misusing diet pills.

Eight participants denied any binge eating behaviors (see Tables 4 for participant medical history).

Table 4: Participant Mental History Treatment

Participants

Counseling

4

Medication

3

Eating Disorder Behaviors

6

Diagnoses

3

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ECR-RS Results Each participant completed the Experience of Close Relationships-Relationship Structures (ECR-RS) protocol prior to the semi-structured interview. Participants rated nine items for the following four separate relationships: 1.

Maternal figure . . .

2.

Paternal figure . . .

3.

Partner . . .

4.

Best friend . . .

The nine items were as follows: 1.

I usually discuss my problems and concerns with this person. . . .

2.

I talk things over with this person. . . .

3.

It helps to turn to this person in times of need. . . .

4.

I find it easy to depend on this person. . . .

5.

I prefer not to show this person how I feel deep down. . . .

6.

I don't feel comfortable opening up to this person. . . .

7.

I'm afraid that this person may abandon me. . . .

8.

I worry that this person won't care about me as much as I care about him or her. . . .

9.

I often worry that this person doesn't really care for me. . . .

Parents.

Ten participants scored a secure attachment with their mother or mother-like figure.

He two other participant scored a dismissive attachment style with the mother or motherlike figure. Seven participants evidenced a secure attachment style with their father or father-like figure. Three participants had a dismissive attachment style with their father or

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father-like figure. Two participants chose to not answer questions about the father.

Partner.

Questionnaire responses indicated the following: 1.

Six participants scored a secure attachment. . . .

2.

One scored a dismissive attachment style. . . .

3.

Four scored a preoccupied attachment style. . . .

4.

One participant did not answer. . . .

Best friend.

Seven participants had a secure attachment style toward their closest friend / sibling.

Three had a dismissive attachment style. Two had fearful attachment style.

Table 5: Participant Experience of Close Relationships-Relationship Structures (ECR-RS) results Attachments Categories Secured Dismissive Fearful Preoccupied No answer Total

Mother

Father

10 2

7 3

Romantic Partner 6 1

2 12

4 1 12

12

Close Friend/ Sibling 7 3 2

12

Raw scores from the ECR-RS suggest that most participants had primarily secure attachment styles. However, interview narratives revealed signs of early relational disruptions or issues with important others. This contradicts results from the

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questionnaire, which mostly indicated a secure range of attachment. I will explore this discrepancy in the final section of this dissertation.

Participant Descriptions I assigned each participant a random number to protect their identity. The numbers denote narrative comments within themes (see Table 6: Participant descriptions results).

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Table 6: Participant Descriptions Result Participants

Descriptions

001

43-year-old female who had weight loss surgery 15 years ago

002

28-year-old male who had weight loss surgery 3 years ago

003

35-year-old female who had weight loss surgery 16 years ago

004

46-year-old male who had weight loss surgery 16 years ago

005

45-year-old female who had weight loss surgery 10 years ago

006

47-year-old female who had weight loss surgery 9 year ago

007

48-year-old male who had weight loss surgery 1 year ago

008

35-year-old male who had weight loss surgery 6 years ago

009

53-year-old female who had weight loss surgery 12 years ago

010

53-year-old male who had weight loss surgery 1 year ago

011

68-year-old female who had weight loss surgery 16 years ago

012

52-year-old male who had weight loss surgery 8 years ago

Participant Narrative Themes: Overview Several themes emerged while reviewing participant transcripts and listening to participant narratives before and after weight-loss surgery. I divided these themes into

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two broad categories: (1) Before the surgery (mind-body disconnection) and (2) after the surgery (mind-body reconnection).

I categorized before the surgery (mind-body disconnection) in the following themes: (a) they loved me when, (b) all about me, and (c) the cost of being overweight. After the surgery (mind-body reconnection) includes the following themes: (a) all about the new me (my mind and body), (b) attachment redefined, and (c) the failures and the reset. All six themes include sub-themes (see Table 7: Participant narrative results).

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Table 7: Participant Narrative Results Life before surgery (Mind- body disconnection) They loved me when‌

Life after surgery (Mind-body reconnection) All about new me

Relational traumas

The new tool to my success

Relationships with caregivers Relationships with romantic partners

My new good life Understanding myself better

Relationship with children

I am still the same, but am I?

Relationship with siblings/friends

Total new mindset

Relationships with my culture and society

New addiction

Support vs resistance

Getting moving

All about me

Attachment redefined

Keep it to yourself

Good enough

My weight was an advantage

Too much attention

Personality is key

The failures and the reset

I am the biggest The cost of being overweight My health paid the price Struggles with basic activities The weight of financial burden How will I die?

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In the first broad category, “Life Before Surgery: Mind / Body Disconnection,” participants described their lives before weight loss surgery. These narratives indicated a disconnect between experiences in participants’ minds and those within their bodies.

Three primary themes and several sub-themes emerged. The primary themes include (a) they loved me when, (a) all about me, and (c) the cost of being overweight.

They Loved Me When This category refers to how participants perceived their treatment from loved ones when participants were overweight. All 12 participants discussed how being overweight impacted relationships with the following: 1.

Romantic partners . . .

2.

Caregivers . . .

3.

Their children . . .

4.

Siblings / friends . . .

5.

Society at large . . .

Subcategories include: 1.

Relationships with caregivers . . .

2.

Relationships with romantic partners . . .

3.

Relationships with children . . .

4.

Relationships with siblings / friends . . .

5.

Relationships with culture / society . . .

6.

Support vs. resistance . . .

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Relationships with caregivers.

Participant narratives included relational traumas or misattunements with caregivers.

However, participants either did not recognize these traumas as such, or they saw them as being possibly connected to their eating and weight issues.

Participants shared a great deal of information about these relationships. For some, their parents were absent. For others, the parents were present but participants did not necessarily feel like they could confide in them. Certain family habits, values and traditions influenced how participants viewed eating and weight.

Participant 011.

“Except I got a little bit distant in a way, because I was the only one out of all the kids who called my father ‘dad,’ but I never called my mother ‘mom.’ I always called her ‘Pearly.’”

Participant 010.

“I was the only one who helped out in the house and cooked for my brothers.”

Participant 006.

“I'm trying to think when we stopped riding bikes. I think my dad was still biking, but I don't think we (rode) with him anymore. I think by the time I got into high school, I got more active in sports. I was involved in softball, pom-pom squad, and everything else.

That was when my big weight loss happened, in high school.”

Participant 012.

“Well, quite honestly, my father did his own thing. I mean he took care of the household, don't get me wrong. He did everything he was supposed to do. He spent a lot of time hanging out with his buddies, drinking, doing whatever. He kind of missed some

63

days, missed years with me.

“As I got older, when he got sick, I had to help take care of him. He couldn't believe I could do half the things that I could do. He kind of almost babyfied me too, (saying) “Oh, you might hurt yourself if you do this.” (I was) a grown man at the age of 23. I'm taking care of him because he had a stroke, and during the time he had the stroke, he couldn't do nothing for himself anymore. He was paralyzed on one side, (but) he is still concerned that I might hurt myself, or that I wasn't coordinated enough, because he missed some of those days growing up.”

Participant 004.

“That's the mama I know. I can only remember snippets of [her]. [Her death] changed my whole being. [Eating] was a comfort thing.”

Participant 002. “[Overeating] never really happened at home. Home was very controlled, food-wise. I can never overeat at home. It was like, ‘Oh, I shouldn't. I'll just eat somewhere else.’ It was more hidden.”

Participant 005.

“My father committed suicide in March. I was already pregnant. I gave birth in May. I graduated from high school in May, and I got married in August. It was a whole lot of stuff.”

Participant 001.

“My mom has always talked negative stuff about me being overweight, my whole life.

So, talking to her about my weight . . . I'm not comfortable with it.”

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Participant 012. “[My mother] would say, ‘You don't leave the table until you finish what's on your plate.’ I could be full, but you couldn't get off that table until you ate the food that she had [made]. So, that kind of promoted overeating.

“I got to the point where I could talk to my mother pretty much about anything, but sometimes I had to kind of pull away. Sometimes you had to grow up. When it's time to get out on my own, I start thinking, ‘OK, I ain't got to eat everything on my plate anymore. I don't have to be forced to just sit there and look at food.’”

Participant 004.

“Eating was a comfort thing. My grandmother comes from the South. She is a stickler: ‘You eat everything on your plate so you're not hungry later.’ You know back then they didn't waste that shit.”

Participant 009.

“I didn't really talk to my mom about my weight. She never judged me or my siblings about our weight.”

Participant 001.

“There wasn't no dad. When I was about six or seven, supposedly he didn't want anything to do with me or my brother ever again, but him and my brother continued on with a relationship that I was not aware of until later on in life. My brother is his biological child. I never saw him ever again.”

Participant 002.

“With my mother, I guess I'm more comfortable. It was always like that. My brother David is more comfortable with my father. I'm more comfortable with my mother.”

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Participant 003.

“It's been tough. Growing up, my dad and I didn't have a very good relationship, because we were the exact same people.”

Participant 004.

“He wasn't a real big part of my life. When my mom passed, he would come and pick me up every now and then. One day he came and got me, and we rode around. I enjoyed it, and he just basically told me, ‘Hey, I got to go back to Trinidad. Your grandpa is sick; I'm going to take care of your grandmother.’ I haven’t seen him since.”

Participant 006.

“Well, my main emotional supporter at that time was always my grandmother. She passed away in 2001.”

Participant 008.

“Me and my mother, we never have been extremely close. My one aunt, who was her favorite sister that passed, she was just like a second mother to me.”

Participant 009.

“You know, they never made fun of me or said anything, but my grandmother would always say, ‘You is gaining some weight.’”

Participant 011.

“I was born in the South. I was about five and my dad's brother visited us. He brought me back with him and I lived with my grandmother and my uncle for a few years.”

Participant 003.

“My mother worked, and so my aunts used to watch me all the time. My aunt that I was closest with, she couldn't have children, so she kind of adopted me. My other aunt

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who was another substitute [mother to me], she got married. I went from all attention to no attention. I'm sure that had some kind of effect.”

Participant 012.

“My mother-in-law and sister-in-law were so shallow against me because I was heavy.

I might have been over 300 [pounds] but not quite at 385 yet. They didn't want me to sit on certain furniture. If you see them now, they both big the way I was.”

Relationships with romantic partners.

Participants described how their romantic relationships affected their weight and eating habits. Some had supportive romantic partners, while others had partners who did not understand participants’ struggles.

Participant 010.

“I trust him. He loved me when I was big.”

Participant 002.

“Before [the surgery] I was like, ‘If she leaves me, it's because, I'm big and I really can't offer much.’”

Participant 003.

“All my friends are like, 'I can't believe you're married to somebody who [loved you before the surgery].’”

Participant 005.

“I know sometimes spouses have a hard time, but he was like, ‘You do what you need to do to make yourself feel better, and then I'll get on board and we'll just do what needs

67

to be done together, and it'll be all good.’ That was incredibly helpful because that's not always the case.”

Participant 006.

“I would explain what I would be going through [trying to lose weight]. He was in the military and had that drill sergeant mentality. That didn't fit.”

Participant 011.

“Well he was so supportive. He's been like, ‘I loved you when [you] was thin, I loved you as you gained weight.’”

Participant 002.

“My wife loves eating too. She's not extremely overweight. She's like 184 or something like that. She just feels overweight, but she's not really overweight.”

Relationships with children.

Clearly some participants recognized how their weight affected their ability to engage with their children.

Participant 001.

“I grew up baking. Whoever was in my house ate it, or I did. It wasn't really me trying to show love, but when I had kids, I definitely enjoyed baking [for] them and watching them enjoy what I made.”

Participant 004.

“I'm still learning that I have to slow myself down when I eat. Because food will get stuck and I throw up and stuff like that. That happens every so often. My kids say, ‘Dad, you're eating too fast, remember to eat slow. You can't eat too fast.’”

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Participant 005.

“I didn’t want to be that person in their thirties and forties that had heart disease or was diabetic and couldn’t do anything. And I couldn’t really play with my kids.”

Participant 010.

“Other moms could play with their kids at the playground. I was obviously out of shape and couldn’t do a lot of playing.”

Relationships with siblings / friends.

Participant 012.

“I got five [siblings and] they weren't like that. They weren't that size. I was the biggest one in the family.”

Participant 007.

“I grew up in a house with five boys. If you wanted seconds, you ate fast. At a very young age, I developed some unhealthy eating habits. It was through competition.”

Participant 002.

“I lost the weight again when me and my brother went on the Atkins diet. I lost another 100 pounds. Then, after that, I gained weight.”

Participant 005.

“I weighed like 175 in high school. I was bigger than my friends, but I wasn’t very, very large.”

Participant 008.

“When I was out with friends, I honestly could not walk and talk at the same time.”

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Participant 003.

I have a female friend who was very experimental in our younger years. I lived vicariously through her. When it was time that I was to experience some of this, she was not happy about it. We stopped talking for a bit.

Relationships with culture and society.

Some participants experienced problems in society (e.g., being bullied) because of their weight. However, eating was also part of their cultural heritage.

Participant 002.

“Before, I felt like people went out of their way to help you go somewhere. Now, thank God, I don't have to. But that has been kind of a thing. Before, I was just the jolly big guy.”

Participant 004.

“Because I was a bigger kid, I pretty much got bullied by some of the older kids that were like six, seven, eight years older than me. As far as my classmates, I was like the outgoing kid. I played sports and stuff like that. So, I really didn't get picked on, unless it was from the older kids.”

Participant 008.

“As I got bigger, I started to stray away from people [and] became more of a loner.

Participant 011.

“In my teenage years, I was a hippy. My mom was built heavier on the bottom. I always had hips, but I had a small waistline. I wasn't considered overweight. If I was buying a suit or something that's two-piece, the top would always fit but the bottom

70

would be tight.”

Participant 002.

“I think a lot of times bigger people feel because they're bigger they have to be sloppy.

They can't dress nice. I'm a hat and a shoe person. You know, my shoes have to look nice. I don't care about gym shoes; dress shoes are my thing. I always had to have nice dress shoes, nice dress clothes: button shirts, ties, bow ties, hats. That was my thing.

Participant 010.

“Society would always treat anyone who's heavier like you're not there.”

Participant 006.

“Seventh grade, summertime. [People are] telling you you’re too big for the shorts.”

Participant 010.

“When you're playing sports, you're the last one picked because you're the heaviest.”

Participant 002.

“In the Mexican community, everything's related to food. I love our food. I think with a lot of immigrant families, food is a centerpiece. Family is getting together; we have to make a dumb amount of food. That definitely was a culture thing.”

Participant 012.

“Oh, it's a cultural thing. Always [my parents were] saying, “Kids overseas is starving.” Well, that might be the case, but that doesn't necessarily mean I have to eat everything on my plate. I never did that with my children.”

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Participant 004.

“It's a cultural thing too. She could never just cook a simple meal. She would cook for an army. You know, ‘You never know who might come by, who might want something.’"

Participant 010.

“I'm Latino, Puerto Rican. We fry everything, we eat everything.”

Participant 007.

“She was taught to cook in a very southern fashion with the fried okra, fried pork chops, chicken-fried steak, fried cornbread. You might get a sense of a pattern here.”

Support vs. resistance.

Participants received mixed messages regarding weight-loss from friends, family, and society and culture. These likely added challenges to participants’ decision-making processes regarding surgery.

Participant 003.

Some people are always going think that [surgery] is an easy way. They're sadly mistaken. It is a life choice. I was 300 pounds at my heaviest. I went to meetings and I watched people [lose weight]. Then something happens and the next week they've put back on, and in a year they're higher than before. It's something in your head. You can dig into the ground with your hands. But sometimes a tool is needed. You need a shovel.

This was my shovel.

Participant 004. “[My grandma,] she's just old school. Old school down south. ‘If you ain't got to have

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surgery, why have surgery?’ She was more worried about me coming out of surgery OK, [based on] her experience with people in her life having surgery. That was her main thing.”

Participant 005.

“I'm really private. I don't share a lot of my stuff. I love my mom and I share stuff with her, but I'm not that person who calls their mom every day. When I told her, she was worried, just because that's what moms do.”

Participant 007.

“She was very supportive of me and the weight-loss program. Whenever I went home to visit, she kept cooking the fried pork chops and always had mounds of food available.

It was always difficult being around her. She was supportive of the idea of the weightloss surgery.”

Participant 008.

“My aunt didn't want me to undergo the knife, but she was supportive. My mother, at the time, was extremely against it. She did come on the day of surgery just to support me, but she told me all the way until they wheeled me into the surgery room that she didn't feel that I should do this.”

Participant 009.

“I think my mom's youngest sister was like, ‘You gonna get that surgery? You know people die from that.’"

Participant 011.

“He was so supportive, like, ‘I loved you when you was thin, I loved you as you gained weight. If it's good for your health and you want to do it, fine,’ but I'm not doing it

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for him. He didn't want me to do it for him. It wasn't that type of situation. But he was supportive. He also said that if it was dangerous, he wanted to know the upsides. It was explained to him, ‘This will benefit her in the long run because of the heart problems, sleep apnea, other things that are going on.’”

Participant 005.

“No one goes on [message boards] and says, ‘Oh, this is great. I'm perfectly healthy.

[Everything went fine with my surgery].’ They all post, ‘This horrible thing happened.’ I knew there were people that were successful, that didn't have problems. It's just hard to find them. I had to really hunt for those success stories, those people that did well and didn't have the one in 1,000 thing [happen to them].”

All About Me All 12 participants described how being overweight affected their (a) feelings, (b) thoughts, and (c) behaviors about themselves. The “all about me” theme includes the following subcategories: 1.

Keep it to yourself . . .

2.

My weight was an advantage . . .

3.

Personality is key . . .

4.

I am the biggest . . .

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Keep it to yourself.

Several participants discussed learning to keep their feelings to themselves.

Some struggled with wanting to protect their mothers or caregivers by not sharing feelings with them.

Participant 008.

“Me and my mother never have been extremely close. I don't want to overwhelm her with my issues because [I don’t know] whether she can handle it or not. In my head, I'm protecting her, because I'm not putting all my emotions on her.”

Participant 001.

“Nobody understands. I pretty much just keep it to myself. I shut down. I stay to myself. I don't talk to anybody.”

Participant 002.

“I was very emotional as a child. I cried all the time for every little thing. I was always the first one to cry if I was about to get slapped or I did something bad. It’s kind of a Mexican thing, like, ‘Hey, don't cry.’”

Participant 005.

“I did talk to my mom. I just feel like I'm extra cautious.”

Participant 006.

“Well, no, [I didn’t talk to my mom about my weight] because she was a yoyo dieter, too.”

Participant 009.

“I was always [wondering] if I could lose weight, and how other people

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looked at me. I might have talked to my dad at one point about it and told him how I felt. He tried to encourage me to love myself and not worry about what others might think of me.

Participant 001.

“He's expressed recently that he might have an issue with my weight. So no, I don't feel comfortable talking to him. I talk to maybe my best friend about it.”

Participant 012.

“I got to the point where I could talk to my mother pretty much about anything, but sometimes I had to pull away. Sometimes you had to grow up.”

My weight was an advantage.

Most male participants took advantage of their size while growing up. Four male participants played football and other sports in which size was an asset.

This allowed participants to receive positive attention from caregivers and others. Participants struggled after high school to maintain their weight, due to the lack of daily activity and structure. This led to less positive attention.

Participant 002. “[In] football culture, being big [is an advantage]. In high school, my senior year, I weighed 315 pounds.”

Participant 004.

“In high school I played football, and I wrestled. In wrestling, my weight would go up and down as I'm trying to make [weight classes]. But it really wasn’t a conscious thing. I was just saw myself as a big dude.”

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Participant 007.

“I wore the bigger pants and things like that, but I was still very active. I got into running. Basketball was always fun.”

Participant 012.

“I started gaining weight around maybe 10, 12 years old. I took advantage of it. I used to play football . . . wrestling, stuff like that through high school.”

Participant 004.

“I learned how to cook at seven. I had a cousin who went through the culinary arts program at Duke. He said, ‘Bro, you cook like I do. You know, you learn from mom. You love doing it. So why don't you go to school and get paid for it?’”

Personality is key.

Participants used their personality to deal with low self-esteem and stereotypes about overweight people. They believed that how they carried themselves was important. For several participants, personality seems to have helped manage feelings about their weight. They could offset their weight with their personalities.

Participant 004.

“Just because you're big does not mean you can't go on a date, or someone won't like you. Focus on your personality, who you are, how you treat people, how you carry yourself.”

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Participant 007.

“I don't think my size had anything to do with my personality. I have a very, very sparkling personality.”

Participant 010.

“I knew I was heavy. I'd made jokes about it, make the situation more friendly, I guess.”

Participant 003.

“I was always like one of the guys. I didn't care about makeup or hair or whatever. My friends, the ones that I seemed to relate to more, were the guys.”

Participant 004.

“My personality is what got me through.”

I am the biggest.

Participants struggled with being singled out due to their weight. Some discussed the hardship of having to go to the “larger” sections when shopping for clothing, or going to different stores than their friends and family.

Participant 009.

“Stuff they didn't want to eat, they'd be like, ‘Here, I don't want the rest of this. You can have this.’ Instead of me saying ‘no,’ I'd just eat it. When I gained a lot of weight and I would go out with my friends, I felt like I was Mikey.6

6

Mikey is a fictitious child that appeared in TV commercials. In the commercial, Mikey’s friends were suspicious about eating the advertised cereal and offered it to Mikey, saying, “Let’s give it to Mikey, he’ll eat anything. Hey Mikey!” Mikey was not a

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They probably thought because I was already big, I was just going to eat leftovers they didn't want to take home.”

Participant 012.

“I had a couple of friends that I could confide in. It’s easy when you got somebody who’s just as big as you or close to it. You can turn to them to kind of stroke my ego for a minute. I got five [siblings], they weren't like that. I was the biggest one in the family.”

Participant 008.

“When I was out with friends, I honestly could not walk and talk at the same time.”

Participant 005.

“As a very young child, I was the only child on both sides of the family. For five years, I was little Miss Princess.”

Participant 008.

“This family I became close with, the whole family was extremely obese. But I came into the picture, and they welcomed me in, and I was the smallest one.”

The Cost of Being Overweight All participants discussed the literal and figurative costs of being overweight.

This accounts for the third “life before surgery” theme, which breaks down into

picky eater and he became a meme (before there were memes) about being willing to eat anything and everything.

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the following subcategories: (a) my health paid the price, (b) struggles with basic activities, and (c) the financial burden.

My health paid the price.

Participant 001.

“I was so heavy that sleeping was a challenge. The weight on my lungs [made it] hard to breathe. It was hard to be comfortable. The weight really started to affect my health.”

Participant 004.

“My doctors were amazed that even though I was heavy, I never had diabetes or high cholesterol, or thyroid. I just had real bad sleep apnea, to the point where I did the sleep study, and they were like, ‘We don't know how you are still here, because you stopped breathing so many times during the night.’”

Participant 005.

“I didn't want to be that person in their thirties and forties that had heart disease or was diabetic and couldn't do anything. And I couldn't play with my kids.”

Participant 006.

“A doctor was telling me how high my cholesterol was. He told me all the yo-yo diets I made in my life destroyed my metabolism. He said I'll probably be on that cholesterol medicine the rest of my life if I don't do anything about it.”

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Participant 009.

“I was like, Well, it's either [surgery] or I die some other kind of way from being overweight.”

Participant 010.

“I had gotten so heavy that my doctor told me I was going to be a type-two diabetic.

My blood pressure had gone extremely high, cholesterol levels as well, so I decided to [have surgery] at that point. I knew that I was jeopardizing my life.”

Participant 002.

“I got cellulitis in my leg and I got put into the hospital. I felt something weird in my right leg. It felt weird, and I felt weak and sick. I didn't know what it was. But, then the next day, I just got those black spots.”

Participant 011.

“I had a lot of medical issues. I developed high blood pressure. I found out I had heart failure. I had a couple surgeries. So, between all the medical issues that added weight, I would get it approved that, ‘OK, this may be what you need to live a quality life, to control some of the things that are going on with your health.’”

Participant 008.

“Oh, it really started with health issues. I developed sleep apnea. It got to a point where I couldn't sleep on my back because I felt like I was suffocating.”

Struggles with basic activities.

Participant narratives suggested that society does not realize that overweight people struggle with basic activities. All participants felt uncomfortable doing “normal”

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activities and felt that their weight cost them personal freedom. This became a major reason for having weight-loss surgery. Participants struggled not only with tasks of daily living—shopping, riding in a car share, etc.—but with enjoying life (e.g., going to amusement parks, playing with their children, etc.).

Participant 002.

“I started realizing, when I go in an airplane, I need an extender. When I go in a car, I have to see if I fit. I always adjust to the world. Why should I adjust to the world? That's when I realized, I can't have other people change stuff around for me to live a comfortable life. That's when it snapped into place.”

Participant 003.

“I was not living a 19-year-old life at 19. I wasn't even living a 35-year-old life at 19.

My knees would hurt. I didn't have energy. I didn't feel comfortable. I couldn't ride amusement rides; that was devastating.”

Participant 011.

“I could still function as a teacher, but anytime you do anything that's physical, weight has a bearing. I wasn't too physical anyway, but I was up and down on the floor with the kids. It affected what I could do and how well I could do it.”

Participant 008.

“When I was out with friends, I honestly could not walk and talk at the same time.”

Participant 010.

“I'll give a perfect example: an amusement park. I'm not going to fit in that ride. I just felt embarrassed about it. I just got up, laughed, said, ‘Oh! This ride ain't for me,’ and I would walk off.”

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Participant 005. “[I couldn’t be] the mom who could play with their kids at the playground. I was obviously out of shape. My cardio wasn't good. I couldn't do a whole lot of playing.

Being that size, you can't play on playground equipment or do the fun stuff.”

Participant 012.

“I had a doctor, and he always wanted me to take these pills. I tried the pills for a month. I'd lose 20 pounds. Then I'd stop taking the pills. I'd gain the weight back. That went on for about a year. Then one day, I went to the doctor's office [and] started crying.

These pills they weren't doing anything for me anyway, so I got to find another means.

“By that time, I had ballooned up to 308 pounds. A coworker had already had the surgery and was losing weight. So, I did some research and ended up talking to a doctor.

He told me, ‘You still have to lose some weight (before the surgery).’ I lost 33 pounds. I was told it's a tool, it's not going to cure it. So, I knew I had to change my eating habits, get more exercise. I went from 308 pounds to like 240.”

Participant 002.

“It changes your entire life. Everything needs to be changed or fixed or moved in a different way for you to do anything normal. You can't get on a roller coaster. If I get an Uber, I have to get an Uber XL, because I have to fit. I can't fit inside a Honda Civic.”

Participant 011.

“I like to dress up and getting clothes was difficult. I had to stop shopping at a regular women's department. If it only went up to 18, it wasn't going to fit me. I had to go to those specialty stores like Catherine's, Lane Bryant, stuff like that. So, we used to have

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shopping outings. We would get together and go to the mall. All my friends would be in the women's department and I had to go off somewhere else to find anything that fit me.”

The weight of financial burden.

All participants discussed the financial burden of being overweight, specifically having to pay more for (a) clothes, (b) cars, and (c) furniture. They also talked about losing jobs because of weight requirements. Participants understood these costs not only in terms of their physical health, but also the burdensomeness of everyday life, as well as financial strain.

Participant 004.

“Normal people get jeans [and pay] 23 dollars, 24 dollars. My grandma buying me jeans, she's having to pay 60. Growing up I always thought I should come out with my own clothing line for big people and make it affordable.”

Participant 007.

“I used to get kicked out of buffets. ‘You have eaten too much, you got to leave.

You've been here for two hours already, sir. You have to go.’ I've eaten a lot at buffets.

Buffets used to lose money on me. Now I lose money on buffets.”

Participant 009.

“When buying clothes, I could never find anything that fit me. When I did get something, it just didn't fit right, and I didn't look right. A lot of times I didn't go anywhere. Like with my daughter when she wanted to go out, I would always be too tired if we had to do a lot of walking.”

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Participant 007. “[In the Navy] I had a lot of weight programs and weight-control programs. When I was 27, I opted for liposuction in my midsection to beat the tape measure. That worked for a while—very painful, very expensive at the time. That’s probably when I noticed it was out of control. I said, ‘You know what? I'm done with the Navy. I'm tired of this.’

“They had a program where if you failed three physical readiness tests, PRTs, then you are separated. I failed my third. I was being admin separated, and I was OK with that.

I resigned to the fact that Navy's not going to be a career for me after all, even though I wanted it to be.”

How will I die?

Many participants thought they would die in one way or another from being overweight. They talked about how their eating had gotten out of control and what led them to have surgery. Each participant had a decisive moment when they realized they needed to make a change. Many participants tried dieting and eating healthy only to feel like their efforts were not working and the weight continually returned. Stress and ongoing health issues were also contributing factors.

Participant 001.

“Every time I dieted, I'd gain even more. What sent me over the edge was when I was pregnant with my first child. I gained a lot of weight. I blew up to like 305. I tried many diets after that and was not successful, and once the health issues started kicking in, that's when I started to see about weight-loss surgery.”

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Participant 002. “[I went on the] Atkins Diet when it was the cool thing, and then I lost another 100 pounds. After that, I gained weight.”

Participant 012.

“I dieted several times and would lose a little bit of weight and gain it back. Lose a little, gain it back.”

Participant 011.

“For me it was a lot of fast food. Not just eating, but eating the wrong types of food.

When I really did start going to school and was on more of a full schedule, a lot of the other stuff was cut out. So, I was either sitting in class all day [or] doing homework at night. Not active.”

Participant 005.

“The first time. I was like 308 pounds or something. I had tried a gazillion [ways to lose weight], which work temporarily.”

Participant 003.

“I was 19. I had gone to my chiropractor and we did some x-rays. He looked at them and he re-did them, and he's like, “Your spine is the spine of like a four-year-old because you're overweight.”

Participant 002.

“I just ate to eat. I never had that relationship with food where it was like, ‘I'm so mad, I'm going to go buy 20 Twinkies and eat them all.’ Or, ‘I'm only going to eat one,’ but then you end up eating them all.”

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Conclusion: Life before surgery.

The sections above paint a picture of participants’ experiences before surgery. Life before surgery consisted of relational traumas and various challenges in relationships with family and friends. Study participants felt they needed to keep their feelings about their weight to themselves. They either tried to use weight to their advantage or compensate with their personality. Finally, being overweight came at cost: (a) physically, (b) emotionally, and (c) financially. The next section examines participant experiences after surgery and how participants’ lives changed in positive and negative ways.

All About New Me All participants shared stories about their “new” selves post-surgery. These stories fell into the following subcategories: (a) the new tool to my success, (b) my new good life, and (c)understanding myself better.

The new tool for my success.

All participants discussed how they used weight loss as a tool to become healthier after surgery. Interestingly, participants seemed to view surgery not as an end to their weight problem but as a method to help manage it.

Participant 009.

“When they saw that I had band slippage, they asked me if I wanted to . . . and I said yes because I wanted to continue my weight-loss journey. I think that the only reason I did it. I needed that extra tool to help me along.”

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Participant 003.

“I need help. I need this tool. It's not a bullet.”

Participant 007.

“People who I see have an unhealthy relationship with food and use overeating as a tool to cope with things [could benefit from the surgery]. It will initially curb overeating because you physically cannot overeat.

“They take away three quarters of your stomach. You are going to eat just a very little bit. If not, you feel some very unpleasant things very quickly. That has been a great tool to keep me in check with maintaining a healthy relationship with food. I am much happier eating little three, four ounces of food more often through the day and having more healthy choices of food. When I see somebody eating this huge plate of food, and they see me eat this little thing, I'm happy as a clam.”

Participant 012.

“When I got into having surgery, I was told, ‘It's a tool, it's not going to cure it.’ I knew then I had to change my eating habits, get more exercise. I went from around 308 pounds to 240.”

Participant 003.

“I was 300 pounds at my heaviest. I went to meetings and I watched people get down, and then the next week they've put back on, and in a year they're higher than they were before. You can dig in the ground with your hands and feel the plant. But sometimes you need a shovel. This was my shovel.”

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Participant 004. “. . . having to go through that whole process again, the down time and all of that. I wouldn't want to miss a lot of work. Am I glad I got it in '02? Yeah I'm glad I got it.”

Participant 005.

“I felt like the weight was coming off and staying off, and that was a motivator.”

Participant 012.

“It changed my life, but . . . I got more people coming towards me, telling me, ‘Good job.’ And it did change how some folks felt about me. That made me resent them because if you didn't like me when I was big, don't like me now because I'm small. Just having surgery makes people think differently. You succeed [and] their reactions are a little different.”

Participant 009.

“I don't want to ever go back to being that person with all the extra weight. I don't ever want to see another 300 pounds.”

My new good life.

Post-surgery, participants’ lives improved greatly. Things they previously could not do, they could now do with ease. They seemed to appreciate how weight-loss surgery positively affected their lives, but they also had realistic expectations about themselves and their futures.

Participant 005.

“It is going to help me get healthy and lose weight if I do what I'm supposed to do, but it's not going to make everything unicorns and puppy dogs.”

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Participant 002.

“It’s definitely better now. Everyone's telling me I look better. There are so many more positives.”

Participant 003.

“I'm not perfect. If I'm 194 pounds, I'm not perfect, but I'm happy and I'm healthy.”

Participant 007.

“I go up and down the stairs better. I haven't had really a lot of opportunity to go hiking in the wilderness and do the hunting activities that I have liked to do because I am traveling around.”

Participant 008.

“On the scale it felt good.”

Participant 009.

“I was able to do a lot more things with my daughter that I wouldn't have been able to normally do, like go to the zoo without being out of breath, and going to the mall, and going shopping with her without being out of breath. In my job I could exercise an hour during my lunch break. So, yeah, it helped me a lot.”

Participant 007.

“They're very happy for me and they see my body change. I'm not this huge person anymore [who has] difficulty getting in and out of cars. I can get out of a car now. It's easy.”

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Understanding myself better.

Participants seemed to gain a better understanding of themselves. They talked about topics including: 1.

A change of mindset . . .

2.

A deeper understanding of oneself . . .

3.

Improved confidence . . .

4.

A new outlook on eating . . .

Participant 005.

“To help keep me on track. I still have that [idea of], ‘I can't eat large volumes of food,’ which is a good reminder to me. I went in with the mindset that it was not going to fix my life. “[Surgery] did help me put myself first. Not in a selfish way, or in every situation, but to consider, ‘How is this going to affect [me],’ not just everyone else.” My life isn't going to be perfectly fine. A lot of people think, ‘Well, if I get the surgery and I lose weight, then life will be better.’ And it isn't. It brings a whole other set of things that you weren’t aware of.”

Participant 006.

“Yeah, I do [think it improved my life]. If I would have given myself time to get to know the person I was turning into, that would have been a little bit better for me. I gained more confidence, even though I was the same me.”

Participant 002.

“I think it was a lot of the confidence kind of thing, too. I feel like it's getting better.

[I’m] opening up a little more.”

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Participant 005 “I went through the drive-through at McDonald’s and ordered myself a quarter pounder. I'm like, ‘I'm going to eat this quarter pounder.’ I ate one bite of it, and I had the lap band, and that was it. I knew that I couldn't eat any more. I wanted to eat more because this was my coping mechanism: ‘Let me just eat this quarter pounder and then everything will be fine.’

“That was my epiphany moment: ‘Oh, my goodness. I can't eat anymore to fix things.’

I don't know what to do. How am I supposed to handle things now? If I can't eat my feelings, what am I going to do now? That was the point where I realized, ‘OK, I have to find some other way to handle things,’ because I obviously can't eat enough to make this stop.”

Participant 002.

“Just as the confidence has definitely helped me a lot more after the surgery.”

Participant 003.

“I wasn't intimate with anybody. I never took my clothes off, so it didn't bother me. I wore my pouch kind of proudly, because it was a road map of what I went through, like what I won't become again.”

Participant 002.

“It's a million times better. It's easier to do travel, it's a lot easier to get in your car, get out of a car. I don't have to really look up a restaurant to see if I'm going to fit, stuff like that. The pun I guess not intended, [but it’s a] huge weight off your back.”

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I am still the same, but am I? Participants continued to feel overweight when they were not. Some suggested they experienced body dysmorphia. Participants described an almost surreal sense of inhabiting their “new” bodies. In some ways, they felt like the same overweight person, and it took time to acknowledge the physical change. Participants seemed to consciously change how they thought about and behaved around food. They recognized that if they wanted to maintain a healthy weight, they would have to think about eating in a more aware and reflective way.

Participant 001.

“I was content with where I was [120 to 130 pounds]. I had lost enough weight. I didn't want to be skin and bones. I have not had plastic surgery and my body is embarrassing from the loose skin.”

Participant 002.

“Everyone's got hidden demons that they can't figure out. After getting the surgery, it's so different. I still do stuff that I know I don't have to do because I'm not that weight any more. I still shop at the big and tall. I feel comfortable there.”

Participant 003.

“We were almost to the ride. And I was like, ‘I can't get on this. I couldn't ride this last year. I can't do this.’ They were all looking at me all weird. [I said], ‘I am going to have to walk down this ride, like shamefully again.’ He's like, ‘You're fine. Everybody around you is bigger than you are right now.’ It wasn't until I actually got in the seat and tied my belt that I was like, Oh, OK.”

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Participant 005.

“I've put on probably about 15 pounds in the past year. I'm like, ‘Oh, my God. I'm so huge,’ then I'll see a picture, or I'll walk by a mirror, and I'm like, ‘Oh, OK. I'm not huge.’

I need to probably mount a full-length mirror somewhere to remind myself, ‘Don't be so hard on yourself.”

Participant 006.

“If I was just looking and seeing my reflection in the mirror when I started losing a significant amount of weight, and I could see the change, I couldn't believe that was me.

It didn't feel like it was me.”

Participant 008.

“To me, I still see myself as the big guy.”

Participant 010.

That was like the weirdest part of it all. You don't feel like you lost the weight at first.

Participant 008.

“On the scale, it felt good. But again, looking in the mirror, I couldn't see it.”

Participant 006.

“Outside of the mirror I still didn't feel like the little me that my body was.”

Participant 010.

“You're still buying your big clothes.”

Participant 002.

“I'm still a big guy. But I did a BMI test with my nutritionist and my doctor yesterday, and they were like, ‘If we take off your skin, you're going to be around 250.’ That’s the

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ideal weight for my muscle and height. I was like, ‘Holy shit! I'm where I'm supposed to be.’”

Total new mindset.

Many participants stated that they had to have a completely new mindset following surgery. They consciously changed how they thought about and behaved around food.

They recognized that if they wanted to maintain a healthy weight, they would have to think about eating in a much more aware and reflective way.

Participant 001.

“Even with gaining a lot of the weight back now, my eating habits have totally changed. I would have never done that before the weight-loss surgery.

Participant 002.

“When we get together with the whole family, I don't feel that, ‘Hey, I have to eat.’

My complete mindset changed.”

Participant 005.

“I wanted to be distracted from the feelings at the time. I started doing more crafts. I did more outside activities, walks outside, and more active things. That helped me process things at my own pace without feeling overwhelmed.”

New addiction.

Participants described their eating issues as an addiction. They had to find substitutes for their addictive behaviors, and struggled to replace eating. They viewed food as an addiction. They also talked about other addictions, and what they did to help with their addiction to food post-surgery.

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Participant 002.

“Food is definitely an addiction. They say when you eat your favorite food, the same type of [chemical in the brain] gets released as if you have your favorite drug. You can feel that. You bite into a brownie and feel that. It's 100 percent a real addiction. It needs to be treated like an addiction. With other addictions and stuff [I have tried to] stop cold turkey, and just strong-arm it. I gave up drinking for three years when I turned 21.”

Participant 007.

“I don't have the addictions with alcohol, smoking, drugs, gambling. Someone [told me], ‘You have a sex addiction,’ but my wife is enjoying that.”

Participant 010.

“I raise birds. I just keep myself preoccupied.”

Getting moving.

Participant 10.

“You feel a little different, especially when you first change. There comes a point when you start to realize that you can move better. Similar to their mindset change, study participants began to realize that this newly acquired energy from the weight loss allowed them to do more and opened up more opportunities.”

Participant 005.

“I refuse to let my circumstances change my outlook on anything. We can move mountains. We could do whatever we want to do. It's just like you got to put your mind to it. I never thought in my life I would teach SCUBA.”

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Participant 002.

“I've gotten addicted to the gym. If I don't do [an hour a day], I get in a weird mood. I don't feel like I helped myself out that day. I'm addicted to trying to put up more weight.”

Participant 011.

“Everything was a little bit easier. I had more energy. I didn't have kids anymore; they were out of the house. I had more energy, more time, everything.”

Attachment Redefined In this theme, participants discussed the dynamics of their relationships post-surgery.

Sub-themes included (a) feeling “good enough” in relationships, (b) getting too much attention, and (c) failure after surgery and having to reset.

Good enough.

Participant narratives suggested that they did not feel good enough for love in the past, but that has changed. They clearly recognized that their weight made people view them in drastically different ways before and after surgery. Sometimes it was positive. Other times, particularly when people discounted participants’ hard work, feelings of insufficiency persisted.

Participant 003. “. . . [and this person said], ‘Hey how you doing?’ And I'm like, ‘I wasn't good enough then and you're not good enough now, buddy.’ I was angry about it because like I said, I wasn't good enough then to be seen like this, so, what makes it OK now? I'm still the same person I was 100 pounds ago. What's the deal?”

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Participant 008.

“They tried to discount all of the work that went into going to the gym four or five times a week [and] changing the eating habits. I can't eat like I used to. They discounted that, and he constantly said, ‘Oh, you took the easy way out.’ They discount the hard work.”

Too much attention.

Study participants acknowledged that they received almost too much attention after surgery.

Participant 010. “. . . and they see you as attractive. Naturally, you feel better.”

Participant 003.

“I felt good. I felt scared. Because I could no longer hide behind that façade. Change is always scary.”

Participant 005. “ I would say things like, ‘Oh, I went to the store, and some guy asked me where [something] was.’ My husband would be like, ‘That guy was probably flirting with you.’

I'm like, ‘Why would someone do that?’ And he's like, ‘Because you're attractive.’ It was a weird thing to me.”

Participant 003.

“Yes, people's perception of me did change. . . . we were still talking, and he's like, ‘I'm coming home for Thanksgiving. I want to hang out. I miss you.’ So, we got together.

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You know in the cartoons with the wolf, where the jaw drops and the eyes get big and the tongue [falls out]? Yeah, that was it. It was awesome.”

Participant 012.

“People were just really shocked at how I had changed. I got a lot of praise. Got a few offers. I'm not going to tell you about that.

“She's all for it. She saw I was more active. We did a lot of walking together, going to the dance club. She played basketball in high school; I did too. So, we would play basketball, we would walk a little bit more, we were more active going places, whereas before I would say, ‘Go ahead, I'll be right here when you get back.’ I think she liked that change.”

Participant 010.

“They see you as attractive. Naturally, you feel better, but that partner next to you starts to realize, ‘Hey, wait a minute. This [other person] noticed my honey.’ You know what I mean? There's been a couple of times, but . . . We're very secure in our relationship for the most part.”

Participant 002.

“I feel like people are meaner now. Before, I felt like people went out of their way to help you go somewhere.”

Participant 003.

“I did have a female friend who was very experimental in our younger years. I lived vicariously through her. So, when it was time that I was to experience some of this, she was not happy about it. I'm experiencing something new for myself. We stopped talking for a little bit.”

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Participant 012.

“My sister-in-law had the surgery. I'm thinking, because she's heavy: ‘You're sloppy.

You stink. You're unkempt.’ I asked her one day, ‘Why are you wearing your clothes hanging off you?’ [She said,] ‘Well, I'm fat.’ I say, ‘Yeah, but I was just as big as you. I wouldn't dress like that.’ I would have a full suit on, cleanest boy you know, everything was in place.”

The failures and the reset.

Weight gain after surgery is not uncommon. Some participants openly shared their struggle with regaining substantial weight and starting over. Even for those who struggled to maintain their weight loss, they seemed able to honestly reflect on what happened.

Interview narratives described (a) what it was like to be overweight, (b) how participants felt about themselves, and (c) how others viewed them. Participants seemed open and honest about the negative aspects of their lives before weight loss surgery, as well as the rewards and challenges that followed surgery. Being heavy had good and bad aspects, and did losing weight. Life and relationships constantly evolved before and after surgery.

Participant 001.

“I stopped working out. If I had the surgery revised, I [would] literally have to be disciplined and in the right state of mind to keep the weight off and not gain it back.”

Participant 011.

“It didn't work permanently like it was supposed to. I have a friend who did it, and she

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is still a size 7 or 9. She got [her weight] all the way down, and she stayed down. I felt like it wasn't successful. It must have been because I didn't make it successful. I didn't keep doing what I needed to do. I have some regrets.”

Participant 004.

“My divorce was big in me gaining weight. Getting married, having a kid that biologically isn’t yours, but you adopted him. Taking on a responsibility as a father. And then you have another kid, but your relationship ain't so hot, and you don't know where it's going. Then eventually going through a three-year divorce.”

Field Notes I recorded all interviews via audio and video to capture each narrative and its distinct emotional feel. One participant experienced acute sadness when explaining that she began emotionally eating because she was abandoned by her adoptive father. She took breaks throughout our interview to manage her emotions. When asked if she wanted to stop the interview, she replied that while it was painful to speak of her experience, she also found it helpful. Most participants agreed that it was good to tell their stories.

Indeed, participants had initially contacted me because they wanted to share.

Most participants agreed that the interview process itself was therapeutic. It helped them reflect on past issues. Several participants admitted to being worried about the interview and did not realize it would be beneficial. Some reported that they had not thought about their surgery in years and had not shared any of their experiences with anyone.

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Chapter V

Discussion, Implications, and Conclusion Introduction In Chapter IV, I presented the quantitative and qualitative results of the study. The quantitative data consisted of the scores from the ECR-RS and demographic information.

The qualitative data consisted of narratives obtained from semi-structured interviews.

This study asked the following primary question: “What are the experiences of weightloss surgery patients and how do their attachment / relationship styles impact their postsurgical life?” Secondary research questions were: “What effect does attachment style have on the decision to have weight-loss surgery? How does the post-weight-loss-surgery patient define success and failure?” Research findings suggested possible answers, which I will address throughout this chapter.

I will examine the findings through the psychodynamic lens of theories on (a) attachment, (b) affect regulation, and (c) relational dynamics. This will provide a rich understanding of participants’ attachment styles, first obtained through the ECR-RS and then discussed via semi-structured interviews. My research findings include: 1.

Interview narratives did not support the results of the ECR-RS. . . .

2.

All participants had some form of unresolved and unconscious relational traumas that led to an insecure attachment style with both parents. . . .

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3.

Participants’ relational trauma / insecure attachment style led to the deployment of the secondary attachment strategy, which then caused the mind to disconnect from the body. . . .

4.

The physical effects of the weight-loss surgery caused the mind to reconnect to the body. . . .

5.

Unresolved and unconscious relational traumas from the past resurfaced and threatened to disconnect the mind and body again. . . .

I will further examine these findings through the theoretical lenses provided by Fonagy, Hill, and McDougall, as well as Wallin. This analysis will illustrate that weightloss surgery patients may face significant challenges in maintaining weight-loss after surgery without addressing psychodynamic factors including history of relational traumas and dysregulation of affect. Finally, I will discuss the implications of findings by addressing implicit relational trauma and subsequent reintegration of affect within the mind and body.

Social workers can help weight-loss-surgery patients in the following ways: 1.

Identify past and current relational issues such as unresolved and unconscious relational traumas . . .

2.

Identify disavowed affects (secondary attachment strategies) that led to unhealthy eating (defense) . . .

3.

Recognize the possibility that patients will have to change how they relate to others, and learn how to regulate affect (emotions) through regulated integration without unhealthy eating (defense) . . .

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4.

Reconnect mind (awareness of their true emotions) and body (unhealthy eating patterns) . . .

5.

Findings and Discussion Finding 1: The narratives from the interviews did not support ECR-RS results.

Understanding the experiences of participants’ post-surgery lives requires understanding their pre-surgery lives. I utilized the ECR-RS for this purpose, anticipating that results would reveal the attachment / relationship styles that participants developed throughout their lives from childhood to the present day. This would have facilitated a reliable and verifiable understanding of participant attachment / relationship styles. I intended subsequent interviews to provide more detail about the results of the ECR-RS. For each participant, I intended the interview to corroborate the findings of the ECR-RS. However, the interviews did not corroborate ECR-RS findings. This suggests that the results of the ECR-RS may have been inaccurate. However, narratives did reveal unresolved and sometimes unconscious relational traumas that participants experienced in childhood. These relational traumas could then be interpreted as evidence of insecure attachment style. This interpretation finds support from attachment theory and Fonagy’s theory of mentalizing.

According to Fonagy, mentalizing refers to “. . . the capacity to conceive of conscious and unconscious mental states in oneself and others” (Allen, Fonagy, & Bateman, 2008, p. 11). This entails an understanding of the internal states within oneself and others, which allows one to conceptualize how one and others feel and think. In addition, mentalizing can be done explicitly or implicitly.

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As explained by Fonagy (2008), the mentalizing process is explicitly stored in episodic memory and has the following characteristics: (a) symbolic or verbal, (b) relatively conscious, and (c) deliberative and reflective. However, the mentalizing process implicitly occurs in the procedural memory and has the following characteristics: 1.

Intuitive . . .

2.

Automatic . . .

3.

Unconscious . . .

4.

Nonverbal . . .

5.

Unreflective . . .

Fonagy (2008) further explains via analogy that mentalizing explicitly is to mentalizing implicitly as taking a driver’s test is to driving. Taking the driver’s test necessitates conscious and verbal responses that occur at one point in time, and is therefore an example of mentalizing explicitly. In contrast, driving is not conscious; it’s a matter of “knowing how,” and is therefore an example of mentalizing implicitly.

The following chart highlights the differences between the findings of the ECR-RS and the Narrative interview of this study.

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ECR- RS

Narrative Interviews

Requires participants to mentalize explicitly

Allows participants to mentalize implicitly

Involves paper and pencil.

Involves open-ended questions and answers in one-to-one direct interactions.

No direct –person-to-person interaction. No opportunity for responses that include exploration of feelings, thoughts and impressions.

The interview created a person-to-person interaction that allowed an exploration of (a) feelings, (b) thoughts, and (c) impressions

Asks participant to give predetermined verbal responses to verbal and closed-ended questions that protect against other interpretations.

Allows participants to articulate their feelings and thoughts about their relationships as they answered Allows interviewer to pick up experiences nonverbally or unconsciously.

Participants could describe experiences without understanding the significance of those experiences, No relational experience between interviewer and respondent.

Participants completed the ECR-RS on their own without explanation or observation of affect or behavior

Answers are subject to conscious, emotional, and reflective re-evaluations and considerations.

The interviews facilitated an empathic attunement within each dyadic interaction, thus producing an authentic relational experience not reflected in ECR-RS data.

The interviews allowed me to learn more, as participants communicated via (a) body language, (b) tone, and (c) affect.

Many participants said that they referred to their relationships with parents as those relationships currently exist—not as they existed in the past—when answering the ECRRS. This demonstrates the use of verbal understanding and episodic memory to describe relationships with others. Essentially, participants were mentalizing explicitly. Thus, this mental representation could have been their frame of reference while answering the ECRRS. Participants were conscious of the questions, and they only had verbal means to

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express their understanding. Responses suggested that most participants had a secure attachment with their parents, in that they focused on current relationships, which they may have perceived as secure at that moment in time.

However, the interview allowed participants to express their feelings and focus on past experiences. They gained access to their pre-verbal experiences, which painted a different picture of their relationships with parents. Even if participants considered their current relationships with parents as secure, they could express nonverbal cues that suggested that in the past, these relationships had been insecure.

Interviews provided richer responses than the ECR-RS. This suggests that analysis would benefit from further exploration of relational traumas that lead to insecure attachment styles. To better understand the experiences of patients after weight-loss surgery, we need to first understand patients’ processes of explicit and implicit mentalizing. Insecure attachment styles are generally formed during an individual’s preverbal and unconscious stages, which may help explain why interview responses differed from ECR-RS results.

Finding 2: All participants had unresolved and unconscious relational traumas that led to an insecure attachment style with both parents. Participants experienced parents as being unreliable or dismissive of emotional needs, which led to insecure attachment.

Relational traumas may be defined as exposure to chronic misattunement and prolonged states of dysregulation in the context of early attachment relationship[s].

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Participants did not necessarily state that their parents were emotionally unavailable, but nonetheless indicated the existence of this unavailability via: 

Body language such as eye contact



Tone of narrative voice



Descriptions of situations, attitudes and effects

Without being prompted, all participants discussed relational traumas in their earlier lives. Many participants seemed unaware or dismissive of this trauma. This lack of awareness and dismissive perspective indicate insecure attachment style (mainly a dismissive attachment style). I propose that these participants experienced the following process: First, they experienced their parents as being unreliable or dismissive of their emotional needs; second, due to these relational traumas, they developed a dismissive insecure attachment style.

Many participants described life experiences that included unconscious and unresolved relational traumatic events. Several reported that their parents died prematurely. Interviews included descriptions of physical abuse, and of prolonged separation from parents. Also, participants reported being emotionally separated from parents even if their parents were physically present. As descriptions of relationships with parents developed, it became apparent that many participants either did not receive emotional parental support, or their parents were emotionally dismissive and / or distant.

One participant said, “When I was in his presence, he did not spend time with me, he did not talk to me.” Another said that his mother died when he was seven, and afterwards, “I only remember snippets of [her].” Another stated, “I was always the first one to cry if I was about to get slapped.” Participants did not necessarily state that their parents were

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emotionally unavailable, but nonetheless indicated the existed of this unavailability via (a) body language, (b) tone, and (c) description of situations, attitudes, and effects.

ECR-RS results indicated that 10 participants scored a secure attachment and two scored a dismissive attachment with their mother or mother-like figure. Relationships with fathers or father-like figures scored six secure attachments and four dismissing attachments, while two participants refused to answer the questions about fathers or father-like figures.

Below are descriptions of non-verbal cues (i.e. body language, tone, and affect) and excerpts from the interviews with 10 participants that exemplify the differences in attachment / relationship style between the ECR-RS and interviews. The remaining two participants whose ECR-RS scores indicated dismissive attachments with both parents revealed similar results in their interviews. Interviews corroborated ECR-RS scores, which suggested that the participants had the capacity to mentalize implicitly about their attachment style with their parents.

Participant 001.

According to the ECR-RS, Participant 001 scored a secure attachment with her adoptive mother. She did not answer the questionnaire about her father. She appeared distant when discussing her relationship with both her adoptive and biological mothers.

She perceived her adoptive mother to be critical of her, particularly when it came to her weight. When discussing her adoptive father, she struggled to look me in the eye and cried at times. These behaviors are common when speaking with traumatized people.

Quotes from this participant’s interview include:

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

“My [biological mother] did not officially sign the papers until I was six months old. I was in foster care because she could not make up her mind whether or not she wanted me.”



“[My adoptive mother] always talked negative stuff about me being overweight, like my whole life, so talking to her about my weight, I'm not comfortable with it.”



“My adopted dad was not a dad to me, because when I was adopted, I was supposed to be all white and I was not. When they brought me home from being adopted, he left my mom.”

Participant 002.

According to the ECR-RS, Participant 002 scored a secure attachment with his mother, but he also described not expressing feelings to his mother, or to anyone else. He said that he was still learning to talk about his feelings with his mother and wife. This calls into question the security of his attachment with his mother.

The ECR-RS indicated that 002 had a dismissive attachment with his father, which the interview reinforced. When 002 talked about this result, he had an awkward and nervous smile. He seemed surprised that the questionnaire uncovered his true feelings about his relationship with his father. He adjusted himself in his chair and opened his jacket, as though he felt relieved that he could express the truth without being judged.

Quotes from this participant’s interview include: 

“I was very passive with breakups and stuff like that: ‘All right, it's over.

That's it; move on.’ I guess I never really broke down at any point, for any reason, in my life.”

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

“Until now, I guess. I never really felt like, ‘Oh my God, I need to talk to somebody.’ I never felt that need to have somebody else enter in my issue.

As I get older, I'm trying it out, with my wife and my mom. I've never really been like that. I've always handled it myself.”



“With my mother, I guess I'm more comfortable [compared to my father]. It was always like that. My brother is more comfortable with my father. I'm more comfortable with my mother.”

Participant 003.

The ECR-RS scored Participant 003’s attachment with her mother as secure.

However, in her interview, 003 described feeling abandoned because her mother had to work and take care of her sick brother. Also, 003 lost aunts through death and marriage.

When asked to describe her relationship with her mother, she was dismissive about her mother’s role and made excuses for her mother. She mainly focused on relationships with her aunts. She appeared disconnected from her story because she spoke very matter-offactly even when she talked about losing her aunts, who were her mother-like figures.

However, I noticed sadness in her eyes when she discussed losing those relationships.

Participant 003 also scored a secure attachment with her father according to the ECRRS. As she described this relationship, she struggled with eye contact, and spoke in a matter-of-fact tone. She demonstrated sadness but did not allow herself to completely feel the emotion. This participant admitted that when she was filling out the ECR-RS, she was thinking about her relationship with her father immediately before his death.

Quotes from this participant’s interview include:

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

“My mother worked, and my aunts used to watch me all the time. My aunt that I was closest with, she could not have children, so she kind of adopted me. She passed away after I turned five. And then, the next month, my brother was born. He had some health issues. The month after that, my other aunt, who was another substitute, got married. I went from all attention to like no attention.”



My dad and I did not have a very good relationship, because we were the exact same people. We butted heads a lot. There was no abuse or anything. I graduated college with honors, and he was just like, “Well I did not even think you were going to graduate high school.” Kind of a standoffish relationship. He just was very, stern.

Participant 004.

Participant 004 scored a secure attachment with both parents on the ECR-RS. During the interview, he revealed that he was thinking about his grandmother and maternal uncle when he took the questionnaire. He was raised by his maternal grandmother and maternal uncle after he lost both of biological parents. He had the insight that his grandmother used food to comfort him about the loss of his mother.

His biological mother died when he was seven years old. His biological father left him to return to his home country when he was nine. During the interview, Participant 004’s words seemed to convey an unclear memory of his parents. He seemed sorrowful that he could not remember his mother. He had a vivid memory of the day his father left him, but he was very dismissive of the experience. He has not had any contact with his father since that day.

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During the interview, Participant 004 changed his body language as he discussed different topics. When talking about his grandmother and how she fed him, he looked anxious, as if he were betraying her. He also seemed defensive about how his grandmother cared for him. When he discussed the loss of both of his parents (but mostly his father), he seemed disconnected. He would look up and avoid eye contact. He also tapped his foot nervously when he discussed the loss of his mother, but did not seem connected to the loss.

Quotes from this participant’s interview include: 

“It was a comfort thing. My grandmother comes from the South, so it's cultural too. She could never just cook a simple meal. She would cook for an army. You know, ‘You never know who might come by, who might want something.’ And she was a stickler: ‘Eat everything on your plate so you're not hungry later.’"



“Probably after fifth grade I started gaining a little bit of weight. My family dynamics changed when I was seven. My mom died, and then my father left when I was nine. We moved in with my grandmother. She raised us from the age of seven to adulthood. So, that kind of was like a trigger for me. As a kid, I used food as a comfort.”



“I can remember vague little things that happened at a younger age. I cannot remember her, so . . .”



“My dad is originally from Trinidad. They had gotten divorced when I was maybe three, something like that. He was not a real big part of my life.

When my mom passed, he would come and pick me up every now and then.

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One day he came and got me, and we rode around. I enjoyed it. He just basically told me, ‘Hey, I got to go back to Trinidad. Your grandpa’s sick.

I'm going to take care of your grandmother.’" I haven't seen him since.

Participant 005.

According to the ECR-RS, Participant 005 scored a secure attachment with her mother and did not answer the questions about her father. She did not share her private thoughts with her mother or anyone else. She was honest about her struggle to let people in, especially her mother. She stated that she did not answer the father questions because her father killed himself when she was 17. She described this event as if it did not happen to her, and appeared distant when discussing the experience.

Quotes from this participant’s interview include: 

“I'm really private. I don't share a lot of my stuff. I love my mom and I share stuff with her, but I'm not that person that calls their mom every day.”



[When asked, “Did your father always have mental health issues?”] “No. Not really that I noticed. It was surprising. None of us saw it coming. I don't remember any kind of . . . [stammering] . . . trigger.”

Participant 006.

According to the ECR-RS, Participant 006 scored a secure attachment with both parents, but during the interview she revealed the difficulties of both relationships. She discussed how her mother struggled with her own weight. As a result, 006 did not feel comfortable talking to her mother about weight issues, including when 006 started to use diet pills at age 13.

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This participant started bike riding to be in a relationship with her father. She continued sports in high school because she knew that her father liked sports. She described her father as being in the house, but he not engage with her or the family until she was around 21 years ago.

When she was 15, Participant 006 became involved with an 18-year-old man, despite her parents’ objections. She became pregnant. As the interview progressed, she admitted that her grandmother was her main support growing up. She looked away when describing her father. She appeared to choose her words carefully, as though she were censoring herself. She laughed nervously. She did not maintain eye contact. She smiled inappropriately and awkwardly.

Quotes from this participant’s interview include: 

[When asked, “Did you turn to your mother when you started gaining weight or when you were upset?”] “No, because my mom was a yo-yo dieter, too.”



“I was not athletic, but my brother was into that stuff. Other than that, I think [bike riding] was about the only athletic thing I would try to keep up and do.”



“I'm trying to think when we stopped riding bikes. I think my dad was still biking, but I don't think we did the bike-riding thing with him anymore. I know in high school, my brother still played sports. I think by the time I got into high school, I got more active in sport. I was involved in softball, pompom squad, and everything. That was when my big weight loss happened, in high school. My dad was not there until I was 21 years old.”

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

“Well, my main emotional supporter at that time was always my grandmother.”

Participant 010.

Participant 010 scored a secure attachment with his parents. He stated that while answering the questionnaire, he thought about his stepfather, not his biological father. His mother remarried and had two other children. Participant 010 acted as caregiver for his younger brothers. He also became the family cook. He described his stepfather as a good guy who took on three other boys who were not his, almost as though 010 considered himself and his brothers to be a burden.

When discussing his mother, 010 appeared dismissive about her remarrying. He appeared distant when describing his stepfather. When he discussed his biological father’s departure from the family, 010 was distant, sad, and flat. He looked away as he described his mother’s separation from his biological father, with whom he has had no further contact.

Quotes from this participant’s interview include: 

My parents separated when we were very young. I was maybe three or four.

I did not see him after [the divorce].



[My stepfather] was a good man. He tried to give us the best. He took on three other boys.



I was the one who helped out in the house and cooked for my brothers.

Either my mom or father was working, I would cook dinner.

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Participant 011.

According to the ECR-RS, 011 had a secure attachment with both parents. She reported being sent away from her parents several times during her childhood. She had no idea why she was sent away. She was the second oldest of 10 and the only one of her siblings repeatedly sent away. During the interview, 011 described herself as “damaged.”

As this participant described the repeated separations of her childhood, she appeared increasingly disconnected, or even disassociated, from them. She appeared to understand that her childhood experiences were unusual. She struggled connecting to (a) the loss of her mother, (b) her weight gain, and (c) the original loss of her parents. Her frequent separations from her parents, along with her weight gain and her affect concerning her experiences, question the secure attachment reported by the ECR-RS. Quotes from this participant’s interview include: 

I came back to live with my mom and dad when I was almost ready for junior high. I had to stay with my other grandparents and uncles and aunts in Detroit for a few years. [She appeared to be sad and confused not truly understanding why she was sent away.]

Participant 012.

Participant 012 scored a secured attachment with his mother and dismissive attachment with his father. He stated that his mother dismissed his overeating and at times his feelings. He felt she was overprotective because she had a miscarriage prior to his birth, and he was her youngest. He reported that his father was not there for him.

Participant 012 spoke about his mother as though he had to protect her from his feelings. He struggled with eye contact when talking about his parents. He nervously

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laughed about his father’s absence. He appeared to see the connection between his relationship with his mother and being overweight. His mother had pushed him to eat even though he was not hungry, which he interprets as maternal overprotection. He struggled with his weight issues and his father’s dismissive behaviors. His reactions to his mother make it unlikely that he had a secure attachment to her, but his interview reinforced the ECR-RS assessment of a dismissive attachment to his father.

Quotes from this participant’s interview include: 

“My father did his own thing. I mean he took care of the household, don't get me wrong. He did everything he was supposed to do, but he spent a lot of time hanging out with his buddies, drinking, doing whatever.”



“I think he kind of missed some days, missed years with me.”



“I could be full, but you could not get up until you ate the food that she had.

So, that kind of promoted overeating. As I [gained weight], because my mother was a healthier person, I think they just figured it was just my traits.”

Participant 007.

According to the ECR-RS, Participant 007 scored a dismissive attachment with both parents. He reported that he struggled with these relationships. He appeared very open to seeing his parents as they were, and he maintained good eye contact. He described how his father was dismissive of his weight issues but minimized his father’s role. He spoke about the deaths of his parents and used humor to cope with this serious topic. He joked about his mother hitting him over the head with a pan. He struggled with eye contact when discussing the loss of his father to an accidental death.

When he was 13 years old, 007’s parents divorced. He chose to live with his father

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because his relationship with his mother had deteriorated. His father was dismissive of his needs and concerns and even took pride in the behaviors of his sons that could be considered destructive or unhealthy. In addition, 007 discussed how his relationship with his mother turned violent and abusive.

Quotes from this participant’s interview include: 

“When I was young, it was very good. Very loving. I was her little Tigger, bouncing around. But as I started to grow and puberty hit, I was paying more attention to the girls. Her claws dug in a little bit deeper. [She] did not like my showing attention towards other women. Our relationship deteriorated at that point.”



“A brawl ensued between my younger brother and myself. She broke us up. She found a frying pan that she hit me in the back of the head with.”



“I think my dad thought it was somewhat comical the way we all ate and fought over the food. I think he had some pride: ‘These are my boys.’ I think he equated bigger as stronger.”



“I ended up being the largest of the five boys, and there was a point when I believe I was the strongest. I think my dad kind of fostered that competition too.

He was an engineer and he probably was doing some experiment on his own, seeing how his kids would grow with different food inputs. He and I had our own engagement. He was very active in our lives, but in different ways. He was very athletic. The joke in the family was that he was building his own basketball team.

All five of us are pretty adept at playing basketball.”

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Participant 008.

This participant scored a dismissive attachment style with his mother and dismissive / preoccupied with his father. He felt his mother was fragile and could not handle his feelings. He reported being preoccupied with his father but admitted to being dismissive of him too. Participant 008 appeared open and willing to share insights into his relationship with his parents. He was sad and angry about how their neglect affected his life. 

“With my mother, we have suffered a lot of deaths. She has lost all her sisters.

Two of her sisters passed like three months apart. She's the only one left. I don't want to overwhelm her with my issues. [I worry] whether she can handle it. In my head, I'm protecting her because I'm not putting all my emotions on her.”



“. . . especially for my father. Our relationship [has been] estranged pretty much my whole life. Early on I had him. He was around and then he just disappeared.

But he always stayed in the same town, 10 or 15 minutes away.”

Based on participant interviews, the 10 participants whose ECR-RS scores reported secure attachments with their mother or mother-like figure in fact had dismissive attachments. This means that all 12 participants had a dismissive attachment to their mother or mother-like figure.

The ECR-RS reported that seven participants had a secure attachment to their father or father-like figure. More likely, all seven had a dismissive attachment / relationship style.

Two participants did not answer the questions on the ECR-RS about the father or fatherlike figure. When asked during the interview about these relationships, participants talked

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about traumatic experiences. Essentially, their fathers abandoned them via physical separation. One father cut off contact when the participant was a child. In the other instance, the father committed suicide during the participant’s childhood. Thus, all participants likely had a dismissive attachment / relationship style with the father or father-like figure. The fact that these two participants refused to consider the context of these relationships in the ECR-RS suggests an avoidance of painful affect. When asked, they were able to express their sadness about the loss of relationships with their fathers.

Due to these relational traumas, the participants developed a dismissive insecure attachment style.

Participants scored secure attachments on the ECR-RS, but their interviews indicated the opposite (insecure, dismissive attachments). Indicators included how participants used and exhibited the following: 1.

Words . . .

2.

Behaviors . . .

3.

Affects . . .

4.

Experiences . . .

5.

Interactions . . .

The theories of Main (1985) help me understand the insecure attachment and intergenerational transmission attachment styles revealed during participant interviews. All participants had some relational trauma in their childhood that “. . . [exposed them] to chronic misattunement and prolonged states of dysregulation

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in the context of the early attachment relationship” (Hill, 2015, p. 136).

Relational traumas such as the loss of a parent through death or divorce can have a major impact on a child’s early attachment relationships. Many participants shared stories about relational traumas with their parents and their parents’ own relational traumas and / or insecure attachment styles. For all participants, one or both parents had weight issues, which may have prevented recognition of participants’ needs.

Main and her colleagues (1985) also created an instrument to identify adult attachment styles: The Adult Attachment Interview (AAI). Through the AAI, Main and others identified the attachment style of adult parents in 40 families in the Strange Situation (Ainsworth et al., 1978). The researchers found that an insecure attachment style continues throughout an individual’s entire lifespan, and they described this process as the intergenerational transmission of attachment styles. Main also concluded that a parent’s adult attachment style affects the infant.

Main used the AAI interviews to mirror different attachment styles of adults and infants as reported in the Strange Situation research (Ainsworth et al., 1978). Secure / autonomous adult attachments mirrored secure attachments in infants; dismissing in adults mirrored avoidant in infants; and preoccupied in adults mirrored resistant or ambivalent in infants. Finally, Main and her colleagues (1985) added a fourth category for both unresolved / disorganized attachment in adult and disorganized / disoriented attachment in infants.

In my research, the adult attachment styles were based on (a) the interviews, (b) notes and (c) responses. I did not utilize the AAI due to its length and required training. My research supports the concept that participants’ attachment styles

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corresponded with the dismissing attachment interviews from the AAI. Steele and Steele (2008) discuss differences in interview responses between clients with different styles of attachment. In the section labeled, “The Insecure–Dismissing AAI Pattern of Response,” the authors describe how interviewees demonstrate their attachment styles via (a) language, (b) tone, and (c) non-verbal cues. The authors give an example of a dismissing adult attachment style interview, as follows: Insecure–dismissing interviews (designated Ds) suggest a speaker with firm or even rigid defenses aimed at keeping actual childhood attachment experiences of rejection or neglect out of conscious awareness or, at least, out of the AAI conversation with the interviewer, in both cases—we presume—to prevent the speaker from becoming upset and potentially disorganized. This latter group of interviewees refrain from disclosing information about their attachment history, so that it is hard to tell whether they can remember but choose not to, or they simply have no conscious access to their past. Commonly, dismissing interviews are evident from verbal insistence on difficulty with recall (e.g., “I just don’t remember”) or a normalizing of experience (e.g., “It was ok” or “They were loving.

Don’t all parents love their children?”), with little or no specific personal memories to support the suggestion of a normally loving experience. In addition, there is evident in some speakers’ dismissing AAIs a marked claim of personal strength that presents the self as invulnerable to any adverse consequences of past attachment experiences. Dismissing interviews typically take one of three forms being primarily idealizing (Ds1), usually accompanied by claims to lack of memory; derogating (Ds2), often accompanied by claims to personal strength; or

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restricted (Ds3), often involving a reasonably clear cognitive retelling of childhood difficulties in a way that is disconnected from the probable feelings linked to these difficulties. Note that in each form, attachment concerns are pushed aside, often accompanied by the speaker’s insistence on lack of memory (e.g., “All is well” and “I don’t remember,” as well as “It was normal, just normal”), most typical of the idealizing (Ds1) subclassification. Other dismissing interviews (e.g., the Ds2 subclassification) include descriptions that deride or mock significant attachment relationships, such as an interview in which a sibling is described as having “looked silly” when she cried at their father’s funeral. Some dismissing interviews, the emotionally restricted (Ds3) ones, are not notable for high indices of idealization or derogation but are striking for the way limited difficulties are described, sometimes with limited anger but without indices of sadness, hurt, or vulnerability.’ (2008 p 10) When comparing the above quote to my interview notes and video footage, it becomes clear that all participants had a dismissive adult attachment style. When combining concepts outlined above by Steele and Steele with quotes from participants in my research, we can make certain conclusions, as described in Table 8.

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Table 8: Forms of Dismissing Interviews Dismissing interviews typically take one of three forms Primarily idealizing (Ds1), usually accompanied by claims to lack of memory

That’s the mama I know. I can only remember, snippets of my biological mom.

(Participant 004) I was always [wondering] if I could lose weight. I always thought about how other people looked at me. I might have talked to my dad at one point and told him how I felt. He tried to encourage me, you know, to love myself and don't worry about what others might think of me. (Participant 006)

Derogating (Ds2), often accompanied by claims to personal strength; or restricted

Nobody understands. I just keep it to myself. I shut down; I stay to myself. I don't talk to anybody. (Participant 001) I was very emotional as a child. I cried all the time. I was always the first one to cry if I was about to get, slapped, or I did something bad. I guess it's a Mexican thing, like, “Hey, don't cry. I wouldn't say that's what changed me, but it was kind of like that. (Participant 002)

Restricted (Ds3), A reasonably clear cognitive retelling of childhood difficulties in a way that is disconnected from the probable feelings linked to these difficulties.

I think my dad thought it was somewhat comical the way we all ate and fought over the food. (Participant 007) I love my mom and I share stuff with her, but I'm not that person that calls their mom every day. (Participant 005) Well, quite honestly, my father did his own thing. I mean he took care of the household, don't get me wrong. He did everything he was supposed to do. He spent a lot of time hanging out with his buddies, he is drinking, doing whatever. He kind of missed some days, missed years with me. (Participant 012) I got to the point where I could talk to my mother pretty much about anything, but sometimes I had to pull away. Sometimes you had to grow up. (Participant 012)

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As noted by Steele and Steele, in all forms of interview responses, “. . . attachment concerns are pushed aside” (p 10.) Responses may also express more than one type of dismissing response or defense. In my research, many participants explained that they did not confide in their parents to avoid being a burden. Participants attributed their parents’ behaviors to difficult upbringings. They made excuses for their parents or minimized the impact of traumatic behavior. Many participants had no awareness of the connection between their parental relationships and overeating. In order to have a relationship with their parents, participants had to be dismissive of their own feelings. Based on data from the interviews and the example of the AAI definition of dismissive attachment, either the majority of participants, or all of them, appeared to have a dismissive attachment style with both parents.

Intergenerational transmission of insecure attachment (Fonagy et al., 1995) occurs when a parent’s attachment style affects their child. For example, As Wallin (2007) states: Dismissing parents may fail to communicate empathy but succeed in conveying a sense of coping and stability. There are also parents whose own vulnerabilities compromise their capacity to respond empathically to the child’s intentional stance toward their mental states. Central among these vulnerabilities are the parents’ own mentalizing deficits as well as the reverberating anxieties triggered by the child’s separateness.” p. 50) Participant interviews indicate the vulnerabilities and deficits described by Wallin, in that participants demonstrated the following behaviors:

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1.

Struggling with inconsistent affects . . .

2.

Appeared to be disconnected from their stories . . .

3.

Did not remember events . . .

4.

Minimized their parents’ role when they shared their traumatic experiences . ..

When I asked participants whether they shared their emotions with their parents, responses included: 1.

“. . . only so much I could say to my mother” . . .

2.

“I feel like I'm extra cautious with my mother” . . .

3.

“I don't want to overwhelm her” . . .

4.

“He just disappeared” . . .

5.

“I think he missed some days, missed years with me” . . .

6.

“Me and my mother, we never have been extremely close” . . .

A secure attachment would entail the ability to share one’s emotions with parents.

However, participants indicated the opposite, thereby reinforcing the likelihood of insecure dismissive attachments.

The dismissive attachment style required participants to deploy a secondary attachment strategy to manage their affect and maintain a relationship with parents.

According to Wallin (2007), secondary attachment strategies form as a result of insecure attachments; they allow the child to compromise feelings and affect in order to have a relationship with their parents. It appears that all participants successfully deployed their secondary attachment strategy of dismissing affect (feelings), which led to overeating as a defense.

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Overeating is a defensive way to manage emotions. The defensive use of food allows the expression of secondary attachment strategies to deny emotional needs. Eating itself is a defensive maneuver to satisfy unmet needs while staying connected to a parent.

Eating allowed participants to no longer express emotions that parents found unacceptable. Food served as a self-regulating tool. Rather than getting what they needed from their parent, participants found comfort with food.

Most participants were surprised by the idea that personal experience could influence weight issues or involve trauma. Some were surprised that unresolved and unconscious relational traumas could lead to overeating as a means of self-soothing. They were also dismissive of their parents’ role in their weight and eating issues.

Participants revealed secondary attachment strategies via quotes such as: 1.

“She was a stickler: ‘Well you eat everything on your plate so you're not hungry later.’" . . .

2.

“I think he had some pride that went along with [his sons’ competition over food], the idea that, ‘These are my boys.’” . . .

3.

“I had a lot of issues with being adopted as well. The baking was probably a part of my emotional eating.” . . .

We can understand eating as a means of coping and feeling better, like addiction in general. This behavior results in the mind not being able to read the body. Overeating might involve the mind’s inability to read the body’s signals of the stomach being full, indicating a mind / body disconnect. The secondary attachment strategy aims to maintain relationships, but it cannot help the child manage feelings that accompany the strategy.

Consequences stem from overeating as a defense and a means of managing affect. In this

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sense, participants do not really manage their feelings or affect at all.

This consequence can be explained through the theory of affect regulation, which addresses the management of feelings. Using this theory, we can see how research participants minimized anxiety by disconnecting or dissociating from their affect, which prohibited the mind from reading the body.

Finding 3: Participants’ relational traumas / insecure attachment style led to the deployment of the secondary attachment strategy, which then caused the mind to disconnect from the body.

Relational traumas and insecure attachment style led to participants deploying a secondary attachment strategy. Relational traumas can be understood as the result of the common trauma of overwhelming affect. One avoids or defends against this trauma by disconnecting emotion and body. The relational trauma is not integrated and constitutes a split between affective experience on one side, and on the other the body’s read of the experience and the brain’s explicit understanding.

Trauma imbalances primary and secondary affects. If individuals cannot regulate and integrate traumatic experiences, they will go into a dysregulated-dissociated state. Hill (2015) described the dissociated self-state as “. . . altered states of consciousness and compartmentalization” (p. 32). Dissociated self-states are states of consciousness categorized as (a) hypo-aroused (parasympathetic), (b) hyper-aroused (sympathetic), or (c) altered.

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Finding 3: Also led to the following effects: 

Parental misattunement leaves the child unable to regulate feelings through interactions with parents.



To self-regulate, the child may disconnect from feelings (affect) about themselves and others, resulting in a dissociated state.



The dysregulated-dissociated state can lead to hypo- or hyperarousal, or a chaotic mixture of both.



If the individual is dissociated, they detach from self and others and learn to separate their emotions from their consciousness (compartmentalization).

Hill’s (2015) theories of affect and affect-regulation provide one way to

understand the possible disconnections / dissociations from participant affects. Hill explains, “Affect is the conscious or nonconscious registration of the ebbs and flows of energy infusing the organism—an expression of the body read by the mind” (p. 6).

Affect refers to how the body and mind communicate with each other, or more specifically, how the mind interprets bodily sensations.

When the body has a physiological response, the mind notices and interprets it.

Hill (2015) described these affects as an appraisal system. This system consists of experiences and perceptions, which alert a person to what is important; it also helps them understand their (a) motives, (b) needs, and (c) desires. Many participants’ affect appeared compromised by relational traumas that possibly caused a disconnection / disassociation between mind and body.

Hill (2015) believes this appraisal system includes two types of affects: primary and secondary (or categorical). The primary affect resides in the right brain, which

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processes “. . . automatic, unconscious processing of emotions (implicit processes)” (p. 5-6). The right brain is also “. . . the nonverbal representation of the state of the body.” The primary affect entails how the body expresses itself without words; it is how a person feels inside. According to Hill, if the primary affect is regulated, a person (a) feels present, (b) adapts to different situations, and (c) has an internal state of homeostasis or balance. If a person’s primary affect is dysregulated, the person will feel unsafe and disconnected from others, and will therefore feel unbalanced. The compromised sense of self will cause an internally dysregulated self-state (p. 5-6).

The secondary or categorical affect resides in the left brain where words are consciously processed as “explicit processes” (Hill, 2015, p 5-6). This affect entails cognitive-verbal manifestation, which relates to emotions including (a) enjoyment, (b) rage, and (c) embarrassment. The categorical affect pertains to outward expressed.

It is conscious and what the individual and others see. In a healthy person, the primary and secondary affects work together. They are aligned. In an unhealthy person, the affects are imbalanced; the secondary affect does not mirror the primary affect.

Many participants exhibited this imbalance when talking about relational traumas.

When participants discussed painful life experiences, I noticed that these experiences caused pain, but participants laughed about them or were dismissive of them, as if they were not actually feeling the pain of the experience. This demonstrates that affect is compromised by trauma, which causes a disconnection / dissociation, ultimately leading to the mind no longer reading the body. Participants’ primary and secondary affective states could be described as imbalanced. They outwardly

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manifested affects such as laughing when discussing tragedies that caused them substantial internal pain.

This imbalance might result from affect-regulation, the ability to manage emotional well-being and tolerate negative feelings (Hill 2015). According to Hill, affect regulation first comes through early parental relationships, which become models for relationships throughout life. This is known as a dyadic regulation. The child learns to regulate their own affect and that is called autoregulation.

Hill (2015) further described the development of healthy and unhealthy affect regulation. Specifically, he identified two types of affect regulation: regulatedintegrated (healthy) and dysregulated dissociated (unhealthy). Hill believes that ideally, a regulated-integrated state occurs when a parent is attuned to her child. In this instance, the child learns to regulate their own affect through integration with the parent. This happens through constant and positive interactions, which lead to the child developing (a) a sense of themselves, (b) self-mastery, and (c) well-being (Hill, 2015).

In contrast, Hill’s (2015) notion of the dysregulated-dissociated state explains the opposite. When the parent is not attuned to the child and its needs, the child experiences dysfunctional affect regulation, in which internal self-states are compromised and their ability to think and feel clearly about themselves and others is skewed.

Parental misattunement leaves the child unable to regulate feelings through interactions with parents. To self-regulate, the child may disconnect from feelings (affect) about themselves and others, resulting in a dissociated state. The

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dysregulated-dissociated state can lead to hypo- or hyperarousal, or a chaotic mixture of both. If the individual is dissociated, they detach from self and others and learn to separate their emotions from their consciousness (compartmentalization).

In my research, many participants’ childhood experiences resemble dysregulateddissociated states, especially parental relationships and overeating. The dysregulateddissociated state, which is seen in relationally traumatized individuals, may have caused a disintegration or dissociation between self-states, thereby contributing to an incoherent or unintegrated sense of self and others. This dissociation / lack of integration possibly began in primary and secondary (categorical) affects. Based on interview narratives, many participants could compartmentalize their feelings and their parents’ misattunement, thereby creating altered internal states when discussing parents and eating.

As children, participants learned to down-regulate and convert their dissociated / unintegrated affect states into bodily forms of emotional states. Without consciously realizing it, many participants appeared to dismiss and disavow their own feelings when talking about their parents. They also disavowed and dismissed their parents’ misattuned actions.

Participant 011 described her upbringing but seemed disconnected from it. She reported being sent away from her parents several times as a child, and that she spent most of her childhood away from home. She had no idea why she was sent away. She was the second oldest of ten and the only one of her siblings frequently removed from her parents. During her interview, 011 described herself as “damaged.” Even though her affect seemed dissociated, she stated that the experiences deeply impacted her.

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The childhood separations obviously constituted relational trauma, but she appeared disconnected, or even dissociated, from this experience.

It appeared that Participant 011 could not express (a) loss, (b) sadness, or (c) anger because she needed to preserve her relationship with her parents. Expressing emotions would have placed blame on her parents, who could not handle her emotions. By characterizing herself as “damaged,� she avoided blaming her parents.

This allowed 011 to believe her parents needed to reject her, thereby justifying their actions and making sense of her abandonment. She wanted a relationship with her parents, which preempted any consideration of them as inadequate. Thus, relational trauma prevented her affects from integrating, causing a split between her primary and secondary affect. She could not read her own emotion, which means her mind could not accurately read her body. This includes the sensation of having a full stomach. Her hunger for a parental relationship probably made her emotionally hungry, which translated into physical hunger.

This split was evident in 011’s nonverbal body language. She had a flat tone and no expression, as though she described experiences that happened to somebody else.

This primary affect (implicit processes and nonverbal cues) contradicted her secondary affect (explicit processes), including cognitive-verbal manifestation or verbal expression (Hill, 2015, p 5-6).

Participant 011 admitted to feeling distant from her parents, especially her mother.

She was the only child in her family who called her mother by her first name. She believed that this separated her from her mother and siblings. She had clearly disconnected from feelings about her childhood. She was not able to feel any

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associated pain. This shows how primary and secondary affects can become imbalanced, and how they affected 011’s ability to accurately read her emotions and body. 

“I came back to live with my mom and dad when I was almost ready for junior high. I had to stay with my other grandparents and uncles and aunts in Detroit for a few years.”



“I was the only child for all of [my extended family]. I had more damage, I guess.”



“My mom thought I did not know my sisters and brothers because I was away from the family. She said I needed to come home. So, I came back home and lived with my parents, but by that time, I had lived with relatives for almost 10 years.”

This relational trauma possibly caused a split between affects. Participant 011 described her early relationship with food, both while living with her parents and her extended family. This might illustrate how food met her emotional hunger. Her extended family indulged her because she was the only child. She could eat anything she wanted at any time. At her parents’ home, she could not eat so readily and had to share food with her siblings. It could be possible that food helped her process emotions when she stayed with extended family. When she was at her parents’ home, she had to process her feeling of abandonment and eat everything on her plate in order to please her parents, even though she was not physically hungry.

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

“Well, I think mostly growing up, I don't recall a special problem or anything. We had that ‘Don’t waste your food’ type of environment. ‘Don't go in there making sandwiches. When I cook a meal, that's when everybody eats.’ With a lot of kids, you don't do that kind of thing. When I was [with extended family], I was the only person there. I could eat whenever I wanted to eat. When I was home, you have to share things and you cannot have what you want when you want it.”

To deploy a secondary attachment strategy, Participant 011 had to disconnect her primary affect from her secondary affect via a dysregulated-dissociated state. She ate in order to dismiss / disconnect from her affect. In the home of her extended family, she ate to avoid feeling lonely without her parents. In her parents’ home, she ate to avoid realizing their emotional absence. She overate at dinner because it measured her parents love for her.

Participant 011’s dysregulated-dissociated state seemed to disconnect her from relational trauma and her eating and weight issues. She admitted being a little overweight for most of her life, but when she was 30 years old, her doctor told her she was obese.

During that doctor visit, she realized she had a problem. Her mother died around this time, but 011 did not consciously link her obesity with her mother’s death. She could no longer hope for her mother to demonstrate love. When directly asked if she saw a link between her weight and the relationship with her mother and her mother’s death, 011 stated she could see how the death could have affected her weight. It is not likely that she would have noticed this link without being asked about it explicitly.

The second example came from Participant 005. During the interview, 005 described

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multiple relational traumas and spoke about them as though she was reading from a laundry list. 

“My father committed suicide in March. I was already pregnant. I gave birth in May. I graduated from high school in May, and I got married in August.”



“I did talk to my mom [but] I feel like I'm extra cautious. It's just one of those things.”



“A little more than a year after I got married, my husband joined the military, and we moved to another state. In a two-year span of time, [there] was a ton of stressors.”

Participant 005 reported her relationship with her mother as secure on the ECR-RS. She did not complete the questions about her father. When describing her childhood, 005 stated that her father killed himself when she was 17. She had a baby, graduated high school, got married, and left home within two years. During our interview, she began to laugh when discussing how those events would have been traumatic for anyone. She said she does not bother her mother with her feelings, which calls into question the ECR-RS results. She reported that her father’s suicide was out of the blue, which raises the possibility that she was not in tune with him. She reported getting pregnant in high school because she felt her future husband understood her better and her parents were comparatively uninvolved in her life. She reported that she had to rely on herself.

The more Participant 005 described her relational traumas, the more she evidenced a dysregulated-dissociated state. This suggests that, like many ambivalently attached people, she focused on obtaining love. She may have been so preoccupied with finding love that she could read herself but not the other. If one cannot regulate affect and keep

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primary and secondary affect in sync, mentalization is not possible. Participant 005 did not acknowledge her feelings. She disavowed her feelings to avoid intolerable grief.

Many participants had similar stories of being in a dysregulated-dissociated mental state (relational trauma / affect) and body (unhealthy eating and onset of weight gain).

Data from the demographic questionnaire and the semi-structured interviews confirmed that relational trauma and unhealthy eating coincided. The demographic questionnaire asked at what age participants realized they were gaining weight. During the semistructured interview, participants reported relational traumas without being asked. The age at which participants recognized their weight gain coincided with the occurrence of relational trauma. Many participants were unable to link these events to each other, and broader research could determine coincidence or correlation.

Research on the mind (relational trauma and affect) and body (unhealthy eating and onset of weight gain) has established a growing link between obesity and relational traumas, including family dysfunction and child abuse (emotional, physical, and sexual).

One significant study by the American health-maintenance organization Kaiser Permanente and the Centers for Disease Control and Prevention is known as “The Adverse Childhood Experiences Study (ACE Study)” (Felitti et al., 1998).

ACE was a quantitative study of medical patients that confirmed a strong relationship between the breadth of exposure to abuse or household dysfunction during childhood and adulthood obesity. “The findings suggest that the impact of these adverse childhood experiences on adult health status is strong and cumulative” (p. 251).

Danese and Tan (1994) reviewed 41 studies that included 190,285 participants. The researchers found that childhood maltreatment corresponded to an increased risk of

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obesity over a lifespan (p 544). According to Argenioa and others (2009), . . . not only sexual or physical abuse but also less severe forms of early-life stress are linked to the development of obesity later in life; and psychological dysfunction is not the only mechanism mediating the elevated risk of obesity in persons exposed to early-life trauma. (p. 543) Felitti (1993) conducted a mixed-methods study and found obese participants “. . . to be different at a highly significant level in the prevalence of childhood sexual abuse, nonsexual childhood abuse, early parental loss, parental alcoholism, chronic depression, and marital family dysfunction in their own adult lives� (p. 732).

Wiederman and others (2008) studied 121 participants seeking weight-loss surgery and found a link between obesity and childhood-trauma experiences. The interaction between obesity and sexual abuse was statistically significant in the prediction of both current / ideal body-weight discrepancy (i.e., body dissatisfaction) and maximum weight fluctuation during adulthood (p. 89).

Michopoulos and others (2015) linked (a) childhood trauma, (b) dysregulation affect, and (c) eating issues. The researchers found that childhood trauma can correspond to emotional eating in adulthood, and posited that this finding could: . . . support a model in which obesity and related adverse health outcomes in stressand trauma-exposed populations may be directly related to self-regulatory coping strategies accompanying emotional dysregulation. [Their] data suggest that emotional dysregulation is a viable therapeutic target for emotional eating in at-risk populations.� (p. 129)

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Finding 4: The physical effects of the weight-loss surgery caused the mind to reconnect to the body.

Weight-loss surgery limits the patient’s intake of food afterwards, which affected participants’ secondary attachment strategy and chronic dysregulated-dissociated states.

Many participants described having to develop a new mindset after surgery, and became more aware of their feelings (affect) due to restrictive eating. Because most weight-loss surgery reduces the amount of food an individual can eat in one sitting, the individual will experience pain if they overeat. This pain allows the mind to read the body again, which might reconnect primary and secondary affect states and interrupt the dysregulated-dissociated state.

This new mindset either allows the post-surgery patient to cope with their affect (stop using their secondary attachment strategy) or find new defenses to manage their affect.

My research found that for some participants, current relational traumas affected longterm results and possibly caused a return to the old secondary attachment strategy of disavowing their feelings. This in turn prompted a return to old defenses including unhealthy eating. Many participants during the interview initially reported that they could not connect their eating patterns with their emotions. These participants may have not been consciously aware of how they used eating and their body to express their affect.

However, weight-loss surgery forced them to acknowledge and respond to their affect.

Once they acknowledge their affect, they experienced what Participant 005 called an “epiphany moment” related to her secondary attachment strategy and the disruption of her dysregulated-dissociated state and use of unhealthy eating as defense.

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One of my kids got hurt at Boy Scouts. He was 10, and got some compression and fractures to his spine. It was a pretty serious injury. And my initial reaction was I went through the drive-through at McDonald’s and ordered a quarter pounder. I'm going to eat this quarter pounder, and I ate like, one bite, and I had the lap band, and that was it. I knew that I could not eat any more. I wanted to eat more, because this was my coping mechanism: ‘Let me just eat this quarter pounder and then everything will be fine.’ That was my epiphany moment. Oh, my goodness. I cannot eat anymore to fix things. I don't know what to do. How am I supposed to handle things now? If I cannot like, eat my feelings, what am I going to do? That was the point where I realized, OK I have to find some other way.

Participant 005 realized that she used eating to regulate emotions. Talking about it apparently made her uncomfortable, because she laughed nervously. This was a primary example of two things: Wallin’s (2007) secondary attachment strategy, and Hill’s theory of dysregulated-dissociated state, via the disconnection between primary and secondary affect.

Participant 005’s secondary attachment strategy involved disavowing her feelings of anxiety and sadness. She perhaps originally deployed this strategy in response to the relational trauma of her father’s suicide. The resulting dysregulated-dissociated state was demonstrated by her first instinct to go to McDonalds as a defense against anxiety and sadness. As 005 described her behaviors in our interview, I could picture her in a dysregulated-dissociated state at the drive-thru, attempting to eat a whole hamburger. Her “epiphany moment” could best be described as a reconnection of the primary and secondary affects and a disruption of the dysregulated-dissociated state.

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Many participants described post-surgery “epiphany moments,” in which they discovered a connection between unhealthy eating and their feelings. Prior to surgery, they could not connect their feelings to their eating behaviors. Many studies have documented weight-loss-surgery patients’ struggle with BED and disinhibiting eating.

Participants in my study could be more appropriately described as engaging in dismissive eating, defined as unconscious dysregulated eating that allows for a disavowal of affect.

This unconscious dysregulated eating can be understood via McDougall (1989), who theorizes a concept similar to Hill’s primary affect state. McDougall’s concept has two elements: a psychic solution (affect dispersal) and an addictive solution. The psychic solution (affect dispersal) separates the self from emotions, resulting in somatization.

These emotions then become reenacted through body symptoms.

McDougall (1989) explains that addictive solutions “. . . take the form of addictive substances, addictive relationships, and perverse or addictive sexual behaviors. Addictive patterns seek to disperse mental pain and psychic conflict, as the mother did in infancy” (p. 82). In these patterns, external objects become “. . . magical attempts to fill the void in the inner world where a representation of a self-soothing maternal figure is lacking, and restore, if only briefly, the primitive dyadic ideal, in which all affective arousal ceases” (p. 82). McDougall explains that this disconnection between the body and the mind (being unable to handle the affective state), results in reversion to non-verbal expression (p 43). Unhealthy eating can be seen as an addictive solution.

Several participants described their eating patterns as addictive. Many reported that relational traumas caused both psychic and addictive solutions. Other studies of pre- and post-weight-loss surgery patients discussed patients turning to other addictions. These

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studies discussed how after weight-loss-surgery, patients had greater challenges with substance abuse and sex addictions. Several participants in my study discussed finding new ways to cope and replace their eating behaviors with other healthier habits (defense).

Participant 010 discussed overeating and how surgery interrupted his food addiction.

He realized that he needs new ways to handle his stress, but apparently still has not connected his relational traumas to eating. He admitted gaining weight after he moved to a new state and was not able to follow up with his doctor. He also discussed how his surgery affected his relationships with his spouse.

Participant 005 realized she used food for comfort and to regulate her emotions.

McDougall (1989) would have said that 005 uses food as a “transitory object.” The transitory object acts as a mental representation of the mother. Much like Hill’s (2015) theory on affect regulation, McDougall believed children learn over time to self-regulate via both relational-soothing (dyadic regulation) and self-soothing (autoregulation).

Babies use inanimate objects, such as a pacifier. to represent an unavailable mother and to provide security in the mother’s absence, until the child learns to regulate herself (auto or self-regulation).

McDougall (1989) also theorizes that in cases of insecure attachment, the child becomes overly dependent on the transitory object to regulate negative emotions and eventually uses it as a coping strategy. McDougall (1989) explains how early anxiety states (relational traumas) can break down the process of using transitory objects. In healthy development, the child eventually learns to self-regulate and not use the transitory object as a means of coping. For many participants in my study, food was a transitory object. Due to relational trauma, many participants struggled learning how to

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cope without food. Interviews included many descriptions of using food to connect with parents and others.

Participants developed new coping skills and defenses. Unfortunately, they did not get to the root of the secondary attachment strategies that led to dysregulated-dissociated states. As a result, many returned to eating because they did not learn how to regulate painful affects.

Finding 5: Participants’ old, unresolved and unconscious relational traumas resurfaced and threatened the success of weight-loss surgery.

Many participants describe post-surgery “epiphany moments.” in which they discovered a connection between unhealthy dating and their feelings. Prior to surgery, they could not connect their feelings to their eating behaviors. Many studies have documented weight-loss surgery patients’ struggles with BED and disinhibiting eating.

Further, participants in my study could be more appropriately described as engaging in dismissive eating, defined as unconscious dysregulated eating that allows for disavowal of affect.

To understand participants’ post-surgical lives, we need to grasp how their parental attachment / relationship styles affect their current attachments. According to Main (1985), adult attachment styles develop in childhood and continue throughout one’s life.

Many participants had insecure dismissive attachment styles in relation to their parents. According to Main, these styles transfer to other relationships. In my study, the ECR-RS indicated that six participants had secure attachments with their romantic partners, while one had dismissive attachment and four had a preoccupied attachment.

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One participant refused to answer the question, stating that they are not dating or in a relationship at this time. The six participants who seemed to have a secure romantic attachment in fact had a preoccupied or dismissive attachment. Many married participants had partners who initially struggled with participants’ new bodies and motivation.

Participants received attention from friends and family, and worried about how their partners would handle this.

The study returned similar results for attachment / relationship style with a close friend or sibling. Instead of seven participants having a secure attachment to their close friend / sibling, all seven likely had a style that was (a) dismissive, (b) fearful, or (c) preoccupied. Participants reported dismissing their feelings to maintain friendships; when they could no longer disavow their feelings, they reevaluated relationships. This could prompt some participants to restart eating as a defense, thereby disavowing their feelings and entering a dysregulated-dissociated state. Revisiting old relational traumas led to post-surgical weight gain via overeating.

Future studies should focus on patients removed from surgery by two or more years.

Several participants in my study underwent surgery less than two years prior to our interviews. Patients within this timeframe appear capable of keeping off weight. They go through a level of body dysphoria and feel disconnected regarding mind and body. They believe they are still large. Participants during this post-surgery window receive encouragement from others, but they also face jealousy or even personal attacks. On this latter point, narrowing the scope to romantic partners might prove beneficial.

Implications for the Social Worker and Medical Field Flores (2004) discussed changing the perception of addiction from a disease to

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attachment disorder. Social workers could then treat patients by providing teaching and helping clients to develop better emotion regulation skills. Also, by creating a holding environment. In this process, social workers could play a large role in weight-losssurgery treatment. Social workers could work with patients to help manage affect and relationship issues. Clinical social workers could help medical teams and their patients understand how attachment styles can affect recovery, thereby affecting better patient outcomes.

Obesity is a growing problem for (a) individuals, (b) family, and (c) society.

Childhood obesity is strongly linked to relational problems (Anderson & Whitaker, 2011). The ACE study concluded that, “Clearly, further research and training are needed to help medical and public health practitioners understand how social, emotional, and medical problems are linked throughout the lifespan.” Such research and training would help physicians treat patients and lead to improvements in public-health programs.

Anderson and Whitaker state, “The magnitude of the difficulty of introducing the requisite changes into medical and public health research, education, and practice can be offset only by the magnitude of the implications that these changes have for improving the health of the nation.” If we can answer these questions, we will better understand post-weight-loss surgery patients from both theoretical and empirical perspectives, and ultimately develop better approaches to treatment.

The following resources would benefit social workers and weight-loss-surgery patients: 1.

Pre-surgical assessment / counseling and education to help identify any relational traumas, addictions, and eating-disorder behavior . . .

146

2.

Pre-surgical counseling to help patients identify and manage their disavowal affects (secondary attachment strategy) and unhealthy eating behaviors (defense) . . .

3.

Post-surgical assessment / counseling and education to help patients (a) identify and manage their disavowal affects (secondary attachment strategy), (b) reconnect their primary and secondary affect, and (c) identify dysregulated-dissociated states and unhealthy eating behaviors (defense) . . .

4.

Post-surgical counseling to help social workers co-regulate with their patients to help them manage their affect . . .

Ethical Considerations and Issues of Trustworthiness As a mixed-methods study, my research used both qualitative and quantitative analyses. The primary approach involved collecting qualitative data while using quantitative methods to enhance the qualitative findings. Findings from mixed-methods studies have varying level of generalizability (Tashakkori & Teddlie, 1998). For the purposes of this study, I used the Experience of Close Relationships-Relationship Structure (ECR-RS) questionnaire, which Fraley and Phillips described as “. . . a contextual self-report measure of attachment . . . designed to assess anxiety and avoidance across several distinct relationships, including relationships with parents, partners, and friends� (2009).

Sibley, Fischer, and Liu (2005) measured the reliability of the ECR-RS in three studies, examining (a) test-retest reliability, (b) convergent validity, and (c) discriminant validity. The researchers found the ECR-RS to be reliable and valid. However, my study

147

is the first to use the ECR-RS in a mixed-methods study to explore experiences and feelings of the post-weight-loss surgery patient.

I transcribed and analyzed qualitative data from interviews by hand. This allowed me to determine themes associated with quantitative data from the ECR-RS. I did not prelabel themes into any words, phrases, or transcript paragraphs, to maintain the exploratory nature of this study.

Limitations of the Study My study focuses on post-weight-loss-surgery patients, a relatively small population.

As a mixed-methods research design that primary used qualitative interviews for datagathering, the sample size is small. The study also focuses on attachment styles and data analysis from attachment and relational theory. One could study numerous other topics (e.g., eating disorders, physical health conditions, etc.) and frame the analysis via other theories (e.g., self-psychology, ego psychology, etc.)

Narrative interviews yield a tremendous amount of data, and one cannot consider every detail or angle when interpreting data. In my study, participants self-reported research data, which introduces the risk of incomplete or inaccurate information.

Participants may be uncomfortable or unable to discuss certain topics. For example, participants struggled reporting anything negative about their parents. In addition, although the ECR-RS has been found reliable and valid, it has never been used in a mixed-methods study to explore the experiences of the post-weight-loss surgery patient.

The ECR-RS was helpful, but the Adult Attachment Interview may have been a better instrument.

148

Conclusion My research asked this primary question: “What are the experiences of weight-losssurgery patients and how do their attachment / relationship styles impact their postsurgical life?” Attachment / relationship styles affect pre- and post-surgical lives via chronic dysregulated-dissociated states and the deployment of secondary attachment strategies. The secondary research questions included: “What effect does attachment style have on the decision to have surgery?” In their childhoods, many participants developed insecure dismissive attachments, which have continued throughout their lives. Multiple participants only decided to lose weight after healthcare providers described weight-loss as a life-or-death matter.

I also wanted to answer the question, “How does the post-weight-loss-surgery patient define success and failure of the surgery?” Eleven participants reported that that their surgery was a success. One reported her surgery a failure because she gained back weight. For the other participants, even though some of their weight returned, they felt that they learned more about themselves.

My interest in the topic is both professional and personal. Professionally, as a medical and clinical social worker, I have treated people who have undergone weight-loss surgery but experienced subsequent weight gain and / or other complications. Personally, I underwent weight-loss surgery more than 18 years ago. I did not receive any psychological treatment before or after the surgery. Since then, psychological treatment has become more readily available to patients. Psychological screenings are now available before and after surgery. This progress is welcome, but I believe more research is needed.

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Appendices

150

Appendix A Flyer

151

152

Appendix B Introduction Letter Telephone/Email Script

153

Hello. My name is Xhosa Burford. I am a doctoral student at the Institute for Clinical Social Work in Chicago. I am working on a research project with the goal of better understanding the experiences of those who have undergone weight-loss surgery and how their attachment/relationships styles might impact the post-surgical experiences.

If you are interested in participating in this survey, I have three brief questions for you which will require no more than 10 minutes of your time.

If the participant agrees, move onto the qualifying questions. If the participant declines, respond by saying, “Thank you for your interest in the study. Have a good day.”

Qualifying Questions 1.

Are you 18 years or older?

2.

Did you have weight loss surgery over a year ago? Date of the surgery?

3.

Are you willing to complete a questionnaire and answer interview questions as part of this research project? The overall process should take approximately two hours and can be scheduled at a time and location convenient for you. At the time of the interview you will receive a $20 Amazon gift card for your participation in the study.

All participants’ privacy and the confidentiality of the data will be strictly protected. Each participant will be assigned a number to ensure anonymity. Data will be stored on a separate password-protected external hard drive that will not be connected to the internet.

Files may be shared in electronic form with the chairperson of my committee. All audio files from the study will be permanently deleted upon final completion of the research study. The information will only be accessible to Xhosa Burford and Dr. Barbara Berger.

If the participant answers “yes” to all three of the questions, respond by saying, “Thank you very much for your interest in this study. May I please have your full name, phone number and email address. Would you like to go ahead and schedule the interview now or would you prefer that I email you with some possible dates and times? I know your time is valuable and I truly appreciate you taking the time to share your opinion for my research.”

Thank you again.

If the participant responds “no” to any of the questions, respond by saying, “Thank you. I am looking specifically for people who are over 18, have had weight-loss surgery over a year ago and are able to participate in the questionnaire and interview process. I know your time is valuable and I truly appreciate your interest in the study and taking the time to speak with me.

Thank you again.

154

Appendix C Follow-up Email Script

155

Greetings, Thank you for agreeing to participate in this study. The purpose of this project is to better understand the experiences of post-weight-loss surgery patients and how their relationships impact post-surgical experiences and outcomes.

Attached to this email are the Formal Consent Form and the Experience of Close Relationships-Relationship Structure Revised (ECR-RS) (Fraley, Waller, & Brennan, 2000) questionnaire. Please review and sign the Formal Consent Form. Then, please fill out the ECR-RS questionnaire and bring the documents when you come for your interview. The ECR-RS questionnaire asks about your “attachment styles” or the types of bonds you tend to form in your relationships with others. Your responses will be made according to a Likert scale, ranging from 1-strongly disagree to 7- strongly agree. All questions are asked about one’s mother or a mother-like figure, father or a father-like figure, dating or marital partner and your closest friend. The questionnaire notes that if you are not currently in a dating or marital relationship with someone, you should answer these questions with respect to a former partner or a relationship that you would like to have with someone. This questionnaire will help to identify your attachment styles.

If you have any questions, please contact me at Xhosaphd@outlook.com or 815-5458512.

Xhosa Burford, LCSW

156

Appendix D Consent

157

Institute for Clinical Social Work Research Information and Consent for Participation in Social Behavioral Research A study of the Experience of Post Weight-Loss-Surgery Patients I, ___________________acting for myself, agree to take part in the research on The Experience of Post Weight-Loss-Surgery Patients.

This work will be carried out by Xhosa Burford (Principal Researcher) under the supervision of Barbara Berger, PhD, LCSW (Dissertation Chair or Sponsoring Faculty).

This work is sponsored by and conducted under the auspices of the Institute for Clinical Social Work; At the Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605, (312) 935-4232.

Purpose The purpose of this study is to explore and better understand your experiences after having undergone weight-loss surgery and understand how your relationships can have an effect on your experiences and outcomes. To gain a better perspective on these issues, the researcher hopes to better understand your pre- and post-surgical experiences.

First, you will be asked to fill out a questionnaire, the Experience of Close Relationships – Relationship Structure (ECR-RS). Then, you will be asked to participate in an in-depth interview that will focus on your experiences and your journey.

Procedures used in the study and duration The first part of the study, the ECR-RS questionnaire, will ask about your relationships: parents, partners and friends. The second part of the study consists of an interview (and possibly a second to clarify answers from the first interview) in which you will be asked open-ended questions about your pre- and post-surgical experiences.

Participation should take no more than two hours. At the time of the interview, you will receive a $20-dollar Amazon gift card for your participation in the study.

Benefits Your participation in this study may contribute to a better understanding of the experiences of those who have undergone weight-loss surgery and how their relationships might impact the post-surgical experience. You may personally benefit because you will have an opportunity to express your feelings about your experiences; there may be therapeutic benefits to participation. Results may also aid in helping develop more appropriate treatment strategies to strengthen the successes of post-weight-loss surgery patients.

Costs There are no costs associated with participation in this study.

158

Possible Risks and/or Side Effects The risks of the study include feeling vulnerable to emotional distress as a result of discussing your journey through the weight-loss surgery experience and family dynamics.

If you have feelings or thoughts of distress, I can pause or stop the interview, and provide a referral for psychotherapy. You have the right to discontinue participation at any time.

Privacy and Confidentiality All participants’ privacy and the confidentiality of the data will be strictly protected. Each participant will be assigned a number to ensure anonymity. Data will be stored on a separate password-protected external hard drive that will not be connected to the internet.

Files may be shared in electronic form with the chairperson of my committee. All audio files from the study will be permanently deleted upon final completion of the research study. The information will only be accessible to Xhosa Burford and Dr. Barbara Berger.

Subject Assurances By signing this consent form, I agree to take part in this study. I have not given up any of my rights or released this institution from responsibility for carelessness. I may cancel my consent and refuse to continue in this study at any time without penalty or loss of benefits. My relationship with the staff of the ICSW will not be affected in any way, now or in the future, if I refuse to take part, or if I begin the study and then withdraw. If I have any questions about the research methods, I can contact Xhosa Burford (Principal Investigator), at this phone number: 815-545-8512 or XhosaPHd@outlook.com. If I have any questions about my rights as a research subject, I may contact Dr. John Ridings, Chair of Institutional Review Board; ICSW; At the Robert Morris Center, 401 South State Street; Suite 822, Chicago, IL 60605, irbchair@icsw.edu.

Signatures I have read this consent form and I agree to take part in this study as it is explained in this consent form which includes being audio recorded during the interview.

Signature of Participant

Date

_________________________________________

_____________

I certify that I have explained the research to __________________________ and believe that they understand and that they have agreed to participate freely. I agree to answer any additional questions when they arise during the research or afterward. _______________________________ Signature of Researcher Revised 14 Oct 2018

________________ Date

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Appendix E

Questionnaire for Weight-Loss Surgery Patients

160 Participant ID: _______

QUESTIONNAIRE FOR WEIGHT-LOSS SURGERY PATIENTS

Demographic information A. Personal Information 1.

What is your gender? a.

Male

b.

Female

c.

Other

2.

What is your age? _________

3.

What is your ethnicity/race?

a.

African American

b.

Asian

c.

Arab

d.

Caucasian

e.

Chicano

f.

Chinese

g.

Filipino

h.

Indian

j. n.

Korean Pakistani

k. o.

l. p.

Native American Other (specify)

i. m.

Japanese Pacific Islander

4.

What is your marital status?

a.

Single

b.

Married

c.

Latino Puerto Rican

Divorced

d.

Long Relationship

5. Are you currently in an exclusive romantic (dating/marital) relationship?

If yes, how long have you been in the relationship? ____________ 6. What is your country of residence?

7. If you are from the United States, in which state do you currently reside?

161

B. Weight History 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

What age did you realize you had a weight problem?

How older where you when you had the surgery?

What was your weight goal?

After the surgery how much weight did you lose?

Did you make your weight goal?

Did you have any medical conditions prior to surgery?

Did you continue to have medical issues after surgery?

Did you regain weight after your weight loss surgery?

If you regained weight how much weight did you gain back?

And how long did you keep your weight off?

C. Mental Health History 1.

2.

3.

4.

Have you ever been in counseling or therapy?

Do you have a history of eating disorders? If so, what kind?

Have you ever been on any medication? If so, for what?

Have you ever had a mental health diagnosis? If so, what was it?

162

Appendix F Attachment Style Questionnaire

163

Experiences in Close Relationships-Relationship Structure (ECR-RS) Fraley, Waller & Brennan http://www.web-research-design.net/cgi-bin/crq/crq.pl ATTACHMENT STYLE QUESTIONNAIRE The next series of questions are about your close relationships and attachment style.

Please answer them to the best of your ability. There are five sections: first is your thoughts about relationships in general and then section about your mother, father, closest friend/sibling and partner relationships. The statements below concern how you feel in emotionally intimate relationships.

This section is interested in how you generally experience the relationship not just in what is happening currently. Respond to each statement by marking a circle to indicate how much you agree or disagree with the statement.

Please read each of the following statements and rate the extent to which you believe each statement best describes your feelings about close relationships in general.

1.

I talk things over with people.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

2.

I'm afraid that other people may abandon me.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

3.

I prefer not to show others how I feel deep down.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

4.

I worry that others won't care about me as much as I care about them.

1

2

3

Strongly Disagree

4

5

6

7 Strongly Agree

164

5.

I find it easy to depend on others.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

6.

I often worry that other people do not really care for me.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

7.

I usually discuss my problems and concerns with others.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

8.

It helps to turn to people in times of need.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

9.

I don't feel comfortable opening up to others.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

Please answer the following 9 questions about your mother or a mother-like figure

1.

I'm afraid that this person may abandon me.

1

2

3

Strongly Disagree

4

5

6

7 Strongly Agree

165

2.

I usually discuss my problems and concerns with this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

3.

I worry that this person won't care about me as much as I care about him or her.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

4.

It helps to turn to this person in times of need.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

5.

I prefer not to show this person how I feel deep down.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

6.

I don't feel comfortable opening up to this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

7.

I find it easy to depend on this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

8.

I often worry that this person doesn't really care for me.

1

2

3

Strongly Disagree

4

5

6

7 Strongly Agree

166

9.

I talk things over with this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

Please answer the following 9 questions about your father or a father-like figure

1.

I don't feel comfortable opening up to this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

2.

I find it easy to depend on this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

3.

I usually discuss my problems and concerns with this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

4.

I'm afraid that this person may abandon me.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

5.

I worry that this person won't care about me as much as I care about him or her.

1

2

3

Strongly Disagree

4

5

6

7 Strongly Agree

167

6.

I prefer not to show this person how I feel deep down.

1

2

3

4

5

6

Strongly Disagree

Strongly Agree

7.

I talk things over with this person.

1

2

3

7

4

5

6

Strongly Disagree

7 Strongly Agree

8.

It helps to turn to this person in times of need.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

9.

I often worry that this person doesn't really care for me.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

Please answer the following questions about your current partner. Note: If you are not currently in a dating relationship with someone, answer these questions with respect to your most significant former partner.

1.

I find it easy to depend on this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

2.

I prefer not to show this person how I feel deep down.

1

2

3

Strongly Disagree

4

5

6

7 Strongly Agree

168

3.

I'm afraid that this person may abandon me.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

4.

I often worry that this person doesn't really care for me.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

5.

I usually discuss my problems and concerns with this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

6.

I worry that this person won't care about me as much as I care about him or her.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

7.

I don't feel comfortable opening up to this person.

1

2

3

4

5

6

Strongly Disagree

Strongly Agree

8.

I talk things over with this person.

1

2

3

7

4

5

6

Strongly Disagree

7 Strongly Agree

9.

It helps to turn to this person in times of need.

1

2

3

Strongly Disagree

4

5

6

7 Strongly Agree

169

Please answer the following 9 questions about your closest friend/siblings

1.

I often worry that this person doesn't really care for me.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

2.

I usually discuss my problems and concerns with this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

3.

It helps to turn to this person in times of need.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

4.

I don't feel comfortable opening up to this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

5.

I find it easy to depend on this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

6.

I prefer not to show this person how I feel deep down.

1

2

3

Strongly Disagree

4

5

6

7 Strongly Agree

170

7.

I'm afraid that this person may abandon me.

1

2

3

4

5

6

7

Strongly Disagree

Strongly

Agree 8.

I talk things over with this person.

1

2

3

4

5

6

Strongly Disagree

7 Strongly Agree

9.

I worry that this person won't care about me as much as I care about him or her.

1

2

3

Strongly Disagree

4

5

6

7 Strongly Agree

171

Appendix G

Dissertation Defense PowerPoint Presentation

172

173

174

175

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