The Importance of SEEING your Weight in Eating Disorder Treatment
By Cheri A. Levinson, Ph.D.
One question I hear a lot from parents, eating disorder providers, and patients themselves, is about weighing. Do I have to be weighed? Should I see my weight? Should I show my patient their weight? But if they do see their weight it causes them distress- isn’t this bad? I’m going to talk a bit about why it is SO IMPORTANT to see your weight when you are in treatment for an eating disorder.
One of the scariest parts of eating disorder treatment is gaining weight. In fact, there is growing evidence supporting the idea that fear of weight gain plays a central role in maintaining eating disorders (e.g., Levinson et al., 2017; Murray et al., 2016). What this means is that being afraid of gaining weight may actually be what keeps an eating disorder going. That means that to get rid of the eating disorder – we need to get rid of (or reduce) this fear!!
So what do we do about this? How do we minimize fears of potential weight gain? This question is so important to us that we are currently working on developing a treatment specifically for fear of weight gain here in the EAT lab. In the meantime, the good news is- there are other treatments out there that work! And part of the reason they are thought to work is because of a practice called open weighing (seeing your weight in treatment). In these treatments patients see their weight once (or twice) a week when they meet with their therapist. Their therapist then plots out their weights across time and then uses this chart in treatment with the patient.
So what are these treatments? Cognitive Behavior Therapy (CBT) and Family Based Therapy (FBT) both use open weighing. These are the treatments we know work best for eating disorders. In fact, FBT is the type of treatment with the most support for adolescents with anorexia nervosa and weekly, open weighing is a non-negotiable part of treatment.
But I still don’t understand why seeing my weight is so important? Let’s do a thought exercise. If I tell you to not think about the purple elephant, what are you going to do? DON’T THINK ABOUT THE PURPLE ELEPHANT….you are going to think about the purple elephant. If I tell you, not only don’t think about the purple elephant, but avoid elephants and anything purple at all costs, what is going to happen? You are going to think more and more and MORE about the purple elephant, elephants in general, and anything purple, and purple elephants are going to become a bigger and bigger deal in your mind.
What do purple elephants have to do with fear of weight gain? The same principle applies to seeing your weight. Our goal in eating disorder therapy is to help patients become less afraid of gaining weight, to realize that gaining weight is not catastrophic, and to put less over-evaluation on weight and shape. The only way that patients can learn that weight is really not as big of a deal is for them to regularly see their weight!!! Patients then learn that just because they have gained weight (or maybe they really haven’t even gained weight like they predicted they would!) the terrible things that they imagined would happen from gaining weight (or seeing their weight) do not happen. After all, your weight is just a number – it does not define who you are as a person!
Perhaps the biggest complaint I hear about this practice is: But if I let my patient see their weight they get really upset, anxious, and it triggers their eating disorder! I get it, it’s tempting to not let patients see their weight. Anxiety is uncomfortable and it’s really hard to see someone who is already in distress get more distressed. Let’s take a deep breath...
I truly believe that the job of the therapist is to help patients learn that they can tolerate uncomfortable emotions. And this is not just me! There is mounds and mounds of literature that shows that learning to tolerate anxiety and distress is actually what makes the anxiety go away and gives you better control of your life. This is what we call exposure therapy and this is how we treat anxiety disorders. By letting patients with eating disorders continue to avoid seeing their weight, we are interfering with learning, we are teaching them that yes, seeing your weight is scary and you SHOULD avoid it. In fact, this is the opposite of what we want them to learn. We want them to learn that they CAN see their weight, it is just a number, and THEY CAN TOLERATE THEIR DISTRESS when they see their weight. The take-away here is this: LETTING PATIENTS SEE THEIR WEIGHT IS ACTUALLY HOW WE REDUCE ANXIETY IN THE LONG TERM.
When I see someone for eating disorder treatment, weekly, open weighing is a non-negotiable part of treatment. In our first session, I take weights and let them know that starting in the following session they will begin seeing their weight, once a week, when they come to treatment. They shouldn’t weigh themselves in between sessions, but they will see their weight and we will talk about their reactions until weighing becomes ‘no big deal.’ I’ve found that the most common reaction to seeing a weight is “oh that wasn’t really as bad as I thought it was going to be.”
So what does this mean for someone with an eating disorder? For a parent? For eating disorder providers? The evidence suggests that we need to be practicing open-weighing. If you are a parent or a patient with an eating disorder and your provider/treatment center does not practice open-weighing- ask them why not? Unfortunately, most eating disorder providers do not practice open weighing, in spite of the evidence (Forbush et al., 2015). If you are a provider or treatment center, it’s up to us to teach our clients that they CAN tolerate being anxious and that their weight is really no big deal. That means we need to make it a point to include open-weighing in our practice.
For more discussion and research on how to best implement open weighing, please see the following two articles:
Waller & Mountfold (2015). Weighing Patients Within Cognitive Behavioral Therapy for Eating Disorders: How, When, and Why.
Forbush et al., (2015). Clinicians Practice Regarding Blind Versus Open Weighing among Patients With Eating Disorders.