My daughter is 16. She was anorexic at 13, but we found a therapist who she liked and was comfortable with. During this period, she gained all her weight in a span of 6 months. As a reward, we traveled overseas for a 6 week visit with family, where she gained several pounds. Upon our return, she immediately began exercising to lose the weight. I watched her as her foods became less and less, and more restrictive to peanut butter, ice cream, chocolate, coffee, and tea. She has purged after binging several time over the past 3 months. It was the purging that brought the relapse to my attention.
I want to my daughter eat and get well, but I am wondering about scales. It is my feeling that it should be removed from the home, particularly since she is not underweight. My daughter weighs herself religiously and it seems to me that to make the home a safe environment, the scale needs to be removed. What is the your view about scales?
Kara Fitzpatrick, PhD responds:
It is wonderful that you noticed and are concerned about setting up a safe environment for your daughter. Relapse often makes us take a second look at our environment and safety nets in addressing eating disordered behavior and it sounds as though you are doing just that. It sounds as though your daughter is using her scale to provide reassurance and feedback that her eating disordered strategies are working and that she has set a narrow range of acceptable weight for herself. To that end, having a scale that she can use for continuous feedback is likely supporting her eating disordered behaviors and I want to empower you to take the steps you feel are necessary to assist your daughter in her recovery – including removing the scale.
However, I do not mean to imply that it is not important for your daughter to get feedback on her weight. This is a common misconception in eating disorder treatment, as many physicians and treating professionals do not reveal weights to patients. Within a family-based approach, knowing one’s weight and having exposure to this information is an important part of treatment, for several reasons. First, anorexia always over-estimates how many calories are being consumed and how rapid weight gain will be. Providing feedback on actual weight gain provides on-going “evidence” that the anorexic thoughts are inaccurate and not tied to actual weight gain. In addition, providing on-going feedback about weight changes helps patients and families monitor and adjust their efforts as necessary – whether it is adding more calories because of the resumption of regular athletic activity or the slowing of weight gain without caloric change as one reaches an ideal body weight. Not knowing weights seems a bit like going to a shooting range without a target to provide feedback! How do you know if your shots are hitting their intended target in the absence of feedback. This feedback becomes particularly important with increased independence where we expect that individuals will be able to manage their weight and shape on their own. This is particularly true in the case of relapse, as your daughter struggles to resume “normal” eating patterns and abandon maladaptive strategies to lose weight (or keep her weight at its current level). What is most useful are standard weights, with time between weigh-ins to avoid focus on minute shifts in weight over the course of the day. In our clinic, we have weekly weigh-ins prior to the onset of sessions and this information is shared with the family to track progress, monitor the impact of strategies and activities in the interim between sessions. Weights are also charted and monitored to look at a trend, rather than focusing on individual weight values.
Relapse is challenging and often those with eating disorders develop new symptoms or eating disordered strategies during relapse that require new skills on the part of their families. At the same time, you and your family have been successful in addressing these skills and challenges previously, so you have a wealth of resources and knowledge to draw upon in facing the challenges ahead.
Kara Fitzpatrick, PhD
Dr. Fitzpatrick is a psychologist working with Eating Disorders at Stanford University/Lucile Packard Children's Hospital and serves as clinical advisor to Maudsley Parents. She is widely trained in a variety of models for treatment and performs research in applied clinical treatments for adolescents and neuropsychological factors associated with eating disorders.