Stepping on the Scale: Not Such a Simple Process: Identifying and overcoming resistance from patient and therapist alike.

eprinted from Eating Disorders Review
July/August Volume 26, Number 4
©2015 IAEDP

Two British psychologists present an intriguing analysis of a seemingly simple and routine step in treatment that is actually very complex: weighing patients. Drs. Glenn Waller and Victoria A. Mountford of the University of Sheffield, Sheffield, UK, and King’s College, London, focused on current protocols for weighing patients during cognitive behavioral therapy, or CBT (Behaviour Research and Therapy 70 (2015), 1-10). 

A starting point for their research was the marked variability in evidence-based therapies, particularly statistics showing that fewer than 40% of CBT clinicians routinely weigh their CBT patients (Int J Eat Disord. 2014 Dec 12. doi: 10.1002/eat.22369. [Epub ahead of print]. And, the authors found that a sizeable number of clinicians believed they should not share weight information with patients. Another issue was that many protocols do not directly address how, when, and why patients with eating disorders should be weighed. 

Four reasons why patients should be routinely weighed

Drs. Waller and Mountford cited four main reasons for CBT therapists to weigh patients with eating disorders: for patient safety, to understand the patient’s eating patterns, to reduce patient anxiety and avoidance, and to modify the “broken cognition” or the patient’s disconnect about the link between eating and weight gain. 

What is the best way to weigh CBT patients? One suggestion is to present the act of measuring weight simply as part of the therapeutic program, beginning with the assessment and the first therapy session. Presenting weighing as a rational and non-negotiable part of therapy will work with most patients, according to the authors, and only a few will question the rationale for it (i.e., ‘My last therapist did not weigh me.’). Exploring the reasons for weight change will help patients see such fluctuations in weight as a slow, boring process and to understand that most people gain or lose up to 2 lb even during the day. For anorexic patients, it is important to discuss the planned weekly weight gain target and to include this in future predictions and evaluations, according to the authors. Yet another suggestion from Drs. Waller and Mountford is that measuring weight be presented as a collaboration between patient and therapist.

The process of weighing

Some suggestions include reminding the patient--before she steps on the scales--that this is only one of four weight measurements used to establish an average weight. Another suggestion is that the patient and therapist view the scale weight at the same time. Then, whatever the weight and whatever the patient’s reaction, the goal is to treat the weight change as a long-term issue and not to get excited about it in the short term. 

Transparency is important, and the weight should be shared with the patient and copies of each weighing kept by both therapist and patient. The authors suggest including two lines on the chart, the actual weight, augmented with a median line every 4 weeks, and the cumulative weight. Then, outcomes after 4 weeks, as indicated on the weight chart, can be used to challenge false beliefs, allowing the clinician to stress the difference between the patient’s beliefs about gaining weight and the actual impact of eating. Thus, the ‘broken cognition’ is repaired with consistent, repeated focus on the eating-weight link. Then, at the end of the session, planning food intake (exposure to ‘feared foods,’ behavioral experiments) and related behaviors (reduction in purging behaviors) should be linked to the patient predicting likely weight change as a result. This prediction is repeated at the beginning of the weighing process at the next session, which will help deal with the fact that the patient’s predicted eating pattern at the end of the session might not be what was actually eaten over the intervening week.

Patient resistance and therapist justifications

Sometimes it’s not only the patient who is reluctant about the process of weighing. Some clinicians are reluctant to weigh patients, even when a shows no reluctance to approach the scale. Therapists’ justifications for not weighing patients may reflect a belief that this will ruin the therapeutic relationship. Or, such justifications many reflect an attitude that the patient is usually weighed by someone else anyway, or that the patient has already weighed herself before the session, or a belief that weight can be judged by eye, or There just isn’t enough time to do it.” 

The authors also found that some organizations have policies about weighing patients that are counter to effective delivery of CBT. Some everyday examples include weighing patients but not revealing the weight or asking other clinicians to weigh patients but then only asking for an update when substantial risk is identified. Some groups require that a patient be weighed only by a specific clinician and only on a particular day, making it impossible for a therapist to weigh a patient during therapy.

Adaptations for specific groups

Certain groups of patients, including inpatients, patients with high degrees of shame about their weight, morbidly obese patients, and those with medical complications, will need special adaptations for weighing. For example, at extreme levels, shame related to being weighed might interfere with the therapeutic alliance and with the individual’s ability to engage in therapy.

Finally, Drs. Waller and Mountford suggest that due to the diversity of current practices, future research should study the impact of training clinicians in the appropriate use of weighing. A second area of research involves the need for specific evidence that weighing is a necessary part of CBT. According to the authors, the overall goal would be to establish protocols that are clear about whether or not to weigh patients with eating disorders, and when and how to do so.