On July 12, Netflix released To the Bone, a drama that stars Lily Collins as Ellen, a 20-year-old woman struggling with anorexia nervosa. The movie has received a lot of attention, including its fair share of criticism. Critics have argued that the film glamorizes mental illness, stereotypes people with eating disorders, and can serve as a trigger to people struggling with or recovering from eating disorders. Marti Noxon, the film's director and a survivor of anorexia, said it was meant to "serve as a conversation-starter about an issue that is too often clouded by secrecy and misconceptions." Mission accomplished!
Opening a dialogue surrounding eating concerns or body image is always a good thing, but viewing the film could truly be harmful for some. Parents are encouraged to watch the film and proceed with caution before allowing young people to view it. If you do decide to watch To the Bone, here are a few topics to consider regarding its portrayal of eating disorders and their treatment:
People with eating disorders and malnourished brains may not be able to "choose" recovery.
A hallmark of anorexia nervosa is anosognosia, the phenomenon of not recognizing how ill you are in the midst of the disease. This condition worsens with malnutrition. Because of anosognosia, patients usually do not want treatment and frequently deny the presence of any problem.
In the movie, Dr. Beckham, played by Keanu Reeves, says patients must hit "rock bottom" to get better. But that idea is dangerous and unrealistic. Many patients can't hit rock bottom because the bottom keeps sinking lower and lower, until something very serious happens, such as suicide or cardiac failure.
When Beckham tells Ellen that he won't treat her if she does not want to be treated, he is repeating an old trope about eating disorders. This could prevent people from getting lifesaving treatment in a timely manner.
"Most experienced eating disorder specialists are very used to treating people who do not want to be treated, or at least not all the time," said Rebecka Peebles, an adolescent-medicine specialist and co-director of the Eating Disorder Assessment and Treatment Program at the Children's Hospital of Philadelphia (CHOP). "This does not need to delay care, nor does it have any impact on their future recovery. If you are worried about your child, get them help. Do not wait for them to get worse."
Common personality traits of people with eating disorders.
The movie showed a lot of fairly energetic dialogue and activity from patients suffering from extremes of malnutrition. In reality, most such patients are depressed, anxious, socially withdrawn, and emotionally flat
"In real life, patients with severe malnutrition often aren't oriented toward relationships, art or other higher-level cognitive activities because all of their energy is going toward basic bodily function," said Laurel Weaver, a psychiatrist and the co-director of the Eating Disorder Assessment and Treatment Program at CHOP. "I think when there is criticism that this film is glamorizing the illness, it's coming from this angle."
But Weaver said the movie seemed to accurately capture some of the "destruction of eating disorders."
The uncontrollable behavior of those with eating disorders – "calorie Asperger's," compulsive exercise, hiding a "purge stash," chewing and spitting out food – are all expressions of the malnourished brain that improve with adequate weight and nutrition.
Eating disorders don't discriminate.
Eating disorders affect people of all weights, ages, races, sexers, sexual orientations, and socioeconomic statuses.
Genetics, environmental factors, and personality traits combine to create the risk for an eating disorder.
Many people with eating disorders don't look sick. They can be underweight for their own bodies without appearing so to others. Although the movie has only one non-Caucasian patient — an African American female who binge eats — and one male, it is important to note that anorexia nervosa can affect many types of people.
Families are a big part of the recovery team.
During a family therapy scene, Beckham seemed to place a lot of blame on Ellen's parents. But parents do not cause eating disorders, and family dysfunction is not a reason to exclude parents from their child's treatment. Parents may not understand (e.g., the cheeseburger farewell cake scene in the movie), and they may feel overwhelmed, confused, or angry, but they are an essential component of the care team and should be empowered to refeed their child.
Treatment that involves the whole family is helpful because the whole family is often affected by the disease, with siblings often ending up as emotional casualties. If families are getting a message of blame or shame from their treatment provider, "they should consider whether it is the correct treatment provider," Weaver said.
It is important to note that all parents and caregivers are important support for patients with eating disorders. In the film, Ellen's father never shows up.
"While this may have been her experience, this is not the typical experience and risks minimalizing the role of all family members in recovery," Peebles said.
Social media can fuel eating-disorder culture.
Eating-disorder sites as well as Instagram are virtual communities that can normalize, encourage, and propagate disordered cognition and behaviors.
If you are a parent, be mindful of your child's social media consumption and of any changes in eating or exercise behavior.
If you are struggling or recovering, recognize the effect social media have on your thoughts.
Additionally, eating disorder treatment facilities can fuel the culture. Typically, these facilities can be supportive, healing environments. They can also be easy places to share tricks and build friendships based on a mutual experience: the eating disorder.
The right way to refeed.
The concept of parent-involved refeeding is evidence-based and often helpful. The scene with Ellen's mother cradling her and feeding her with a bottle is uncomfortable, however, and not what is recommended for treatment in 2017.
Family-based treatment (FBT) is the gold standard for treating children and adolescents with eating disorders and can also succeed with young adults. Because malnourished brains are unable to choose and consume the appropriate type and quantity of food, parents are encouraged to step in and temporarily take control of what, when, and how much their child eats. Once the child is weight-restored, parents can help gradually transfer age-appropriate autonomy back to their child.
Even families who do not choose FBT for their child are still critical supports through treatment. "Any treatment or treatments that help families get their child to the finish line of recovery are terrific," Peebles said. "Parents are often valuable members of the team in helping choose the right paths at the right times."
Weight loss risks relapse.
Collins, a survivor of anorexia nervosa, reported that she lost weight under the supervision of a nutritionist to play this role.
"This is horrifying," Weaver said. "Weight loss for any reason is a risk factor for relapse."
The most protective thing a survivor can do to prevent relapse is maintain appropriate weight. That means age-appropriate weight gain during childhood and adolescence, followed by weight maintenance in a range that is normal for the individual's unique body rather than the bare minimum BMI for height.
In the end, full recovery is possible with early detection and intervention, and the first and most critical step in treatment of a restrictive eating disorder is weight restoration, which allows for behavior improvement and development of insight over time.
To learn more, or if you or someone you know is struggling, here are some resources: