The general hypothesis of the present study was that pre-operative predictors of sustained success (over three years) for GBS patients would differ according to pre-operative stress level. This hypothesis followed from the previous findings of major differences in outcome predictors between patients with good and poor pre-operative medical health
The present results showed several predictors of success in common for both low-stress and high-stress patients: good support from family and friends, good personal coping skills, and good psychological and cognitive functioning.
However, the groups differed as follows. The major characteristic of the successful low-stress patients was their strong and broad expectations for major life improvements-spanning work-related, social, physical, and general confidence and life-satisfaction areas. In addition, these patients had been in their major relationship for only a relatively brief period of time, and the overall number and range of personal support variables was even stronger than for high-stress patients. For the high-stress patients, the strongest predictor was the presence of a troubled relationship including separation, a lack of interest and/or knowledge regarding health matters (in general and also regarding their own health status), and some possible adjustment difficulties during adolescence
It is instructive to compare these results with those of the previous study, in which the outcome predictors for good pre-operative health and poor pre-operative health patients were studied. Similar to present study, the strongest predictors for the good-health patients involved strong and broad expectations for massive life improvements. But interestingly, these patients had relatively poorer psychological adjustment and poor self-concept. And analogous to the present findings, a strong predictor for the poor pre-operative health patients was poor knowledge and little interest in matters involving health information in general and also in their own health. But the poor-health patients who improved the most had massive personal support and were happy and well-adjusted-essentially, they were happy people who were being were fully and completely taken care of.
In viewing the present results, it is logical to view high pre-operative stress as potentially interfering with progress (continued weight loss), noting that the low-stress patients did not have such interference. The task confronting the low-stress patients was a more straightforward one. It is no surprise that success for both groups was related to the variables that predict success in any therapeutic endeavor: good coping skills, good personal support, and good personal adjustment. But a major predictor for low-stress patients was a strong expectation of success across many life areas. This characteristic, termed self-efficacy by Bandura [9
], has been repeatedly shown to be a strong predictor of successful therapeutic change.
What of the patients with high pre-operative stress? The results suggest that many of them had serious relationship problems-perhaps the cause of the high stress; and it can be speculated that a desire for a better relationship might have been a driving force for successful sustained weight loss. Their lack of interest in health matters suggests that their approach to change was idiosyncratic or autonomous, rather than following specific instructions on what they were “supposed” to do.
The pattern of findings in both the present and the previous study show some degree of correspondence with predictions that could be made from self-determination theory as applied to health contexts [10
]. A basic tenet of this theory is that “behavior change is more effective and lasting when patients are autonomously motivated” (p. 325). Also included is the importance of three basic psychological needs to “motivate the initiation and long-term maintenance of health behaviors” (p. 326): autonomy, competence, and relatedness. Such themes can be seen in the variables related to success in the present authors’ work. It is particularly noted that for patients with extra burdens (poor health; high stress), the successful patients were those who ignored the “rules”-the conventional health-related knowledge-and simply did it their own autonomous way. And for the good-health and low-stress patients, the motivation for successful change appears to have been intrinsic-the personal drive to have a better life, rather than based on external factors.
A word should be said about two unexpected variables that were found to be related to success in the present study: significant alcohol use for low-stress patients, and habitual tobacco use for high-stress patients. As a possible explanation, it is noted that Table 2 shows many interpersonally relevant predictors for the low-stress improvers, compared with relatively few for the high-stress improvers (Table 3). Given than alcohol and tobacco are, broadly speaking, utilized as stress reducers, it is consistent that the high-stress patients utilized the more socially related behavior (alcohol), versus a non-personal stress reducer (smoking) by the high-stress improvers. It is noted that “social drinking only” was shown to be a specific predictor of success for the former group.
Several limitations of the present study should be recognized. First, in regard to the follow-up data, it is noted that the procedures for obtaining participants’ weight after three years were somewhat rudimentary. This would have had the potential effect of reducing the reliability of these data. In future work, it might be preferable to obtain this information in the context of individual in-person interviews. A second issue involves the considerable variability in the extent to which patients participated in post-operative support groups and individual counseling. The effects of this activity on ultimate outcome remain unknown. Third, it is recognized that the study utilized a large number of predictors, yielding a comparatively small number of significant correlations (although greater than would have been expected by chance alone). While none of these limitations are likely to have biased the basic findings of the study, they should be taken in to consideration in future research of this nature.
The results of the present study add to previous findings that useful moderators can be found for enhancing pre-operative prediction of outcome in GBS. It would be of interest to investigate these variables (health status, life-stress) and possibly others (e.g., general psychological adjustment) for their possible relevance in improving outcome predictions in other significant life interventions, whether surgical or of another type.