Dans cet article, nous montrerons que la croyance en une « métamorphose » identitaire du sujet en obésité grâce à la chirurgie bariatrique est une construction imaginaire que soignants et soignés ont en partage dans ce type de clinique. Nous analyserons les causes et les répercussions que ces fantasmes peuvent avoir sur la prise en charge, tant au niveau des vécus des patients que des pratiques des soignants. Enfin, nous proposerons l’idée que l’événement chirurgical et ses conséquences vont s’inscrire, à l’inverse d’une « métamorphose », dans une continuité subjective pour la personne opérée ; en témoigne l’insistance de certaines expressions symptomatiques à travers et au-delà des changements organiques ou comportementaux liés à l’opération. Il s’agira ainsi de réfléchir aux modalités d’accueil et d’accompagnement des personnes en obésité lors d’une prise en charge en chirurgie bariatrique aujourd’hui.

In this study, we will show that the believing of an “identity metamorphosing” of the subject with obesity by bariatric surgery is a fantasy construction built by both patients and caregivers. We will analyze the reasons and the repercussions of these fantasies on the care, both on the patients’ subjective experiences and on caregivers’ practices. At last, we will propose the idea that the surgical event and his consequences will be inscribed, at the opposite of a “metamorphosis”, in a subjective continuity for the operated person, as the insistence of symptomatic expressions across and beyond the organic and compartmental changes linked to the surgery reflects it.

Most of the patients investigated for this study were treated with Sleeve Gastrectomy and Roux-en-Y Gastric Bypass but some of them were not treated yet and expected for a surgery. In all cases (i.e. when they were not operated yet and when they were asking for a second surgery because in failure by gaining weight), they were brought to discuss on their surgery request. Surgery-experienced patients also have to comment the surgery's effects on their body and its image, their eating behaviors and their relationships with the others (companion, friends, family, etc.). For caregivers, the results are extracted from different clinical discussions about patients or about ways of caring all along the multidisciplinary support. Patients and caregivers were both asked to talk about their representations on bariatric surgery.

We observed two types of fantasies: “split” fantasy built by patients and “recovery” fantasy built by caregivers. The “split” fantasy is the believing of a magical and ideal surgery that allows “identity metamorphosing” of the subject with obesity. For these patients, “split” fantasies can be related to the desire of the other or can appear through weight's objectives. For the caregivers, and as “split” fantasies, “recovery” fantasies can be related to an idealization of the operation in itself and the obesity “psychiatrization”. On the other side, we have seen that some psycho-sensory symptoms emerged after surgery: patients present disgust for aliments they used to appreciate. By discussing with these patients, we realize that these aliments were associated with traumatic experiences and memories that potentially lead them to construct their obesity. These symptoms seem to be an opened-door to the operated subject's unconscious and are related to the subject's psychical continuity.

The identity metamorphosing resulting from bariatric surgery is a fantasy built by both patients and caregivers. These fantasies have an influence on the medical support and potentially lead the treatment to failure. They should be identified and analyzed before the request, during the transformations due to the operation itself, and after weight stabilization (when the operated subject continues to reorganize his relationships to the other and to the culture pressure). Also, as the symptoms produced by bariatric surgery mobilize traumatic memories from before, they reveal a subjective truth: the traumatic past cannot be erased by body changes. And if the patient's past continues to be ignored by caregivers, it is condemned to repeat itself and potentially compromising the treatment at term. Thus, caregivers should be able to pay attention to the subjective continuity of the patient's history in order to ameliorate the reception and the accompaniment of persons with obesity in a bariatric surgery procedure.