Most clinicians have heard that it is “better” to not tell patients with eatings disorders their weight. Although taking blind weights can be helpful, the decision whether or not to tell a patient their weight is actually context dependent. Sometimes it is helpful and other times it is harmful. Here we will discuss these conditions and how to approach disclosing weekly weights to patients.
Thinking of learning weekly weights as an exposure exercise often helps clarify the decision whether or not to tell a patient their weight. After all, for many patients in eating disorder treatment, being told their current weight by a treatment team member triggers intense negative emotions such as anxiety. As in making the decision to start any exposure therapy exercise, the therapist much assess 1) the patient's readiness, 2) current skillfulness in tolerating negative emotions, and 3) likelihood of engaging in safety behaviors. In this case, a therapist needs to make sure that a patient is 1) willing to be told their weight once per week, 2) has the ability to report the intensity of their emotions on a scale of 0-10, and 3) has agreed not to engage in eating disorder safety behaviors (e.g. restricting and purging) in response to the negative emotions triggered by knowing their weekly weight.
Particularly early on in treatment, disclosing a weekly weight can cause very intense negative emotions (e.g. anxiety) at a time when they do not yet have skills to regulate those emotions. As such, eating disorder safety behaviors (e.g. restricting meals, purging, etc.) may occur. Since the most important goal early on in treatment is to decrease eating disorders behaviors (to foster medical stability), anything that gets in the way of that goal should be tabled for later in the recovery process. Always remember that from a patient-safety perspective, the focus of treatment must be on what will most immediately foster medical stability (i.e. decreasing eating disorder behaviors and increasing recovery behaviors). Before more nuanced emotional tolerance skills (e.g. tolerating the anxiety that comes with knowing one's weight) are able to introduced, a stable behavioral pattern must first be established.
Further, from a psychological perspective, exposure therapy is not effective when safety behaviors are performed. If a patient effectively avoids the negative emotions that come with knowing one's weight by engaging in safety behaviors (e.g. skipping the next meal), it is the eating disorder behavior that is reinforced, not the skill of tolerating negative emotions. In other words, the exposure therapy exercise is not effective because the result is the patient becoming more reliant on eating disorder behaviors rather than skills. As such, we only want to employ exposure therapy exercises like disclosing weekly weights when the patient is willing and able, so that eating disorder behaviors do not increase and emotional tolerance is learned. In short, if the patient is not willing and/or able to know their weekly weight, then it is better from both a medical and psychological perspective to simply take blind weights once per week.
Although some patients may not be willing and able to know their weekly weights, others are! If so, then a weekly exposure therapy exercise can be set up. In this case, the therapist asks how intensely the patient is experiencing negative emotions on a scale of 0-10 right before the patient learns their weight as well as after. The therapist then sits with the patient until the negative emotions and any urges to engage in eating disorder safety behaviors goes down.
Here is a brief assessment that can be used in determining if a patient should be told their weekly weight:
Is the patient willing to be told their weekly weight as an exposure exercises?
Does the patient have a low to moderate (not extremely high) amount of anxiety about their weight?
Is the patient is likely to use skills to manage negative emotions triggered by knowing their weight (instead of engaging in intolerance behaviors such as restricting or purging)?
If the answer to all three of these questions are “yes,” then it is likely appropriate to attempt disclosing weekly weights to patients as an exposure exercise. If the answer to any of these questions is “no” then use blind weights.
Hopefully this clarifies the process of determining whether or not to employ blind weights with a patient! Please feel free to leave any questions and comments below.