The impact of in-session weighing in eating disorder services on the therapeutic relationship: A flexible, transparent and reflective approach

Enhanced cognitive behavioural therapy (CBT-E) is the most widely researched therapeutic modality recommended by the National Institute of Clinical Excellence (NICE) guidelines for the treatment of eating disorders. According to CBT-E, in-session weighing, that is, weighing the client each week during therapy sessions, should be a ‘non-negotiable’ therapeutic intervention. Despite research supporting CBT-E, there is no research that supports in-session weighing as a ‘non-negotiable’ aspect of therapy. Furthermore, CBT-E posits that behavioural change precedes the therapeutic relationship, which is problematic for counselling psychologists who posit that an empathic, safe and trusting therapeutic relationship are key ingredients to therapeutic change. This paper critically reviews the ways in which ‘in-session weighing’ can impact on the therapeutic relationship.Searches were made for literature pertaining to in-session weighing; protocolled treatment for eating disorders; ethics in eating disorder treatment and the impact of non-negotiable therapeutic interventions on patients with an eating disorder diagnosis. Qualitative, quantitative and theoretical papers were included in the review.Based on the literature, this paper argues that in-session weighing, if carried out in an entirely protocolled-driven way, risks overlooking the therapeutic relationship and the individual differences of the clients we meet. However, the paper suggests that CBT-E can be synthesised with counselling psychology’s relational ethos by adopting a flexible, transparent and reflective use of in-session weighing.Such an approach takes into account the clinician’s own values and biases, the context of the client, the presenting difficulties and the clinic setting. Such an approach lends itself to the holistic underpinning of counselling psychology.