In a successful recovery, weight plays a very complicated role. On the one hand, the obsession with weight is a core symptom of the disease, a preoccupation the mind of the ill person. For clinicians, restoring and monitoring weight remain one of the best indicators for continued health and progress.
These distant poles of illness and recovery can play a demoralizing game of tug-of-war between encouraging the eating disorder and maintaining recovery, especially if the therapist isn't careful. Striking the right balance between monitoring weight and staving off obsession is challenging. In the end, treatment needs to gradually relegate weight to a less important status in recovery and identity, a tight rope walk that's critical to free someone from the prison of the eating disorder.
Weight is not only the focus of people with eating disorders but a national obsession. The public health obesity crisis, the media focus on thinness and the universal reach of the diet industry all point to the endless public appetite for weight obsession. The universality of the focus on weight applies to clinicians too: no one is immune.
So when a patient expertly couches their pathological weight obsession as if it were within the norm of society, it's too easy for the clinician to fall into the trap. The conversation can become familiar, casual, without sensing the danger. The result is the patient feeling validated: yes their own weight obsession is normal. They aren't really that sick.
Similarly, living with an eating disorder in today's world encourages and rewards successful weight obsession. Weight loss invariably leads to an endless string of compliments. Weight gain by someone who was underweight triggers the rounds of "You look so much better," as if weight gain were synonymous with full recovery.
Even treatment providers can't help but acknowledge and comment on weight as a marker of success or failure. No matter how much it's explained that recovery is not about weight, society says otherwise. In fact, weight appears to be the only way people are able to understand these confusing psychological illnesses. It's much clearer to discuss weight than to understand why someone cannot eat.
The best path for recovery is somewhat counterintuitive. Once weight isn't at a dangerous level, ignore it. Focusing on weight validates one core belief of the eating disorder: the number on the scale is the most important marker for success.
Since the goal of treatment is for life to become meaningful, that powerful number must be devalued right away and regularly. The only value of weight in therapy is as a marker of health, but tracking meals each day and monitoring variety and intake of food, though time consuming, is much more valuable. Health is connected with nourishment, not weight. Following the number more often reflects too simple an approach in treatment and at times too punitive a stance if weight is used to measure progress, a mindset very much akin to the eating disorder.
Unfortunately, the treatment team may find a false clarity in following weight when the best tracking is a lot more ambiguous. If any eating disorder treatment appears that simple, something is wrong. In fact, therapy requires complexity and ambiguity, two qualities most challenging to the ill person, to demystify the simple yet destructive rules of an eating disorder. Any treatment relying on such a simple marker of weight has little chance to succeed and is likely playing into the hands of the illness.
To avoid the pitfalls of weight, it behooves the therapist to explain the role of weight in recovery right away. Weight only matters if it's at a dangerous level and thus a clear sign of severe illness. That's mostly the case if someone is in inpatient or intensive outpatient treatment. Anyone medically stable shouldn't have weight be the primary assessment of health.
It's essential to educate the patient and family that weight stability is only a small part of recovery. Health is a necessary prerequisite for effective treatment because the mind and body need to heal in order to change behaviors and alter one's life course. However, a therapist needs to quickly dispel the myth that normal weight equals recovery.
Putting weight in its proper place in treatment begs the question what does constitute the successful path of treatment. The answer lies in a series of complex tasks: face the challenge and emotion of eating each day, come to terms with the unpredictability of daily life, accept illness and recovery as an obstacle to living more fully and, most importantly, search for people and things that make life much more meaningful than the number on the scale.