Ten Things I Want Viewers of To the Bone to Know

“To The Bone,” Marti Noxon’s semi-autobiographical film about her experience as a young adult living with anorexia, was released today on Netflix and has already stirred up much controversy within the eating disorder community. As a general rule, I do not see things in black and white. As with anything, I see this film in shades of grey – it handles some things well and some things poorly. Many concerns have already been aired widely in both mainstream and social media.  Foremost among these concerns is the movie’s reinforcement of the anorexia nervosa stereotype by portraying an emaciated white female and the weight loss that lead actress Lily Collins underwent to play the role. I will not rehash these here; instead, I hope to shed light on some other important issues and to provide an educational piece to accompany the film.

1. This film may be triggering. It shows images of severe emaciation and may either be upsetting to those vulnerable to eating disorders, or inspire a competitive desire to be “as skinny”. Often, people with eating disorders don’t feel “sick enough”; anorexia nervosa can be a competitive illness. (Reports are that pro-ana sites are already using images of Lily from the film. While it’s concerning that the film adds to the available library of these sorts of images, this library is already huge – if they didn’t use this image, it would be easy to find another.) Those susceptible must exercise caution when viewing this film and if they are triggered, they should contact their treatment team or contact an organization such as the National Eating Disorders Association for help.
2. It is difficult to make a film that accurately portrays eating disorders. To depict eating disorders on film, behaviors must be shown. Yet much of the suffering from an eating disorder is internal and harder to depict. This film is not an educational film – it is a piece of entertainment. Nevertheless, I think it does bring eating disorders into the mainstream. The film portrays some things accurately – with others it takes great liberties. Even with these departures, I do think it has virtues that can do some good. I will discuss these more below.
3. This is one person’s story. Marti Noxon’s aim is to tell her story and she has a right to do so. She has been public that many years ago she suffered from an eating disorder and wanted to both shed light on and draw more attention to the issue. And that she has done! Based on the talkback I attended with Marti Noxon and actors Lily Collins and Alex Sharp, Marti recognizes that she can neither represent the diversity of all people with eating disorders nor speak for the range of people affected. She hopes that her work will open the door for others to tell their own stories, a hope I share. For those interested in a more diverse story about eating disorders, check out the work of Tchaiko Omwale, who is working to complete her film Solace. If you are committed to helping bring more diverse voices forward, you can contribute to help her complete her film.
4. To The Bone accurately portrays some of the aspects of living with an eating disorder. I do not believe the film overly glamorizes anorexia. It illustrates the mindset and some of the mental anguish of someone with an eating disorder. The film displays a number of common eating disorder behaviors. We see Ellen and her peers engaging in behaviors such as calorie-counting, dietary restriction, overexercise, bingeing and purging, and chewing and spitting. Chewing and spitting is displayed in a restaurant scene in which Ellen goes out to eat with Lucas, her friend from treatment. Chewing and spitting is a lesser-known, but significant eating disorder behavior that is not commonly talked about or assessed by professionals. It is a frequently associated with more severe eating disorder symptoms and suicidal ideation. However, the behavior is more likely to occur in private than in public. It can occur in the context of anorexia nervosa as well as bulimia nervosa or other disorders.

5. Eating disorders are serious mental illnesses and can be life-threatening. The movie shows Ellen and some of her peers needing medical attention and carefully balances showing the gravity of their situation with building hope for recovery.
6. To the Bone paints a very Hollywood picture of recovery. While the movie adequately portrays Ellen’s ambivalence about treatment, it implies that things shift when Ellen “decides” she wants to recover. It disturbs me greatly that Dr. Beckham tells Ellen, “I’m not going to treat you if you aren’t interested in living.” Many people with anorexia nervosa have anosognosia, a symptom that causes patients to deny their illness and refuse treatment as a result. We now know that enough food, weight gain, and a cessation of eating disorder behaviors are prerequisites for recovery from anorexia nervosa. Usually some physical restoration is required before a patient can really want to recover – Dr. Ovidio Bermudez calls this a “brain rescue.”
7. The movie does not model modern eating disorder treatment practices. But realistic treatment would probably not make a good Hollywood story. For starters, I would never suggest a therapy patient change his/her name! More seriously, in eating disorder treatment we prioritize nutritional recovery. This refers not to specific nutrients, but to the development of healthy eating habits including regular meals and adequate amounts of food. This applies to people with all eating disorders, not just anorexia nervosa. People with eating disorders need as a primary element of treatment food – balanced, sufficient, and regular eating. The movie portrays the patients in the residential treatment center as each able to choose their own food. While some patients eat some portion of the meals served, other patients eat nothing (or the one character with BED repeatedly eats only peanut butter out of the jar). I know of no treatment setting that would not have a primary focus on structured regular meals and patients having requirements for meals that can become less restrictive as they progress in treatment.
8. I worry that the portrayal of Ellen’s family reinforces old myths about eating disorders being caused by families. To reiterate, families do not cause eating disorders. Ellen’s father is unavailable (and never even appears), her mother has had mental health problems (and is involved in a new relationship) and no one is really there for Ellen, except her stepmother who takes her to treatment and her half-sister. I do love the portrayal of the relationship between Ellen and her half-sister. I think this relationship captures the mixture of love, concern, and anger experienced by siblings.
9. The movie misses the opportunity to depict the family as important allies in treatment. No one is really involved in Ellen’s treatment beyond the family session, and Dr. Beckham states there is no need for any future family sessions on the basis of how badly it went. None of the young people in this house have their parents involved in their treatment (at least that we see). This is very unrealistic in this day and age. Almost every treatment center involves family members to a greater or lesser degree. In reality, parents can play a central role in the treatment of adolescents and young adults, are usually included in treatment, and can even drive the treatment when their youngsters are incapable of seeking treatment on their own or have anosognosia. Parents can also help with nourishing their youngsters back to health (but not in the dramatic way it was portrayed in the film…with a baby bottle). Family-based treatment (also referred to as the Maudsley method and mentioned in passing in the scene where the moms are in the waiting room waiting for their daughters to have an intake with Dr. Beckham as something they have tried) is actually the leading treatment for adolescents and is also effective for many young adults. It focuses on empowering the family to be an important part of the treatment team and able to fight for recovery on behalf of an unwilling or unmotivated youngster and also provide meal support.

10. Three Things I really like about the film:
    1. I love that Dr. Beckham says, “There is never one cause.” This is true.
    2. I love that it builds hope for recovery by showing Lucas as doing well and actively working on recovery.
    3. I love that it shows a male and an African-American with eating disorders.

Although I was a consultant for the film, I had no influence on the story.

In conclusion, please View the Nine Truths PSA the cast and crew of To the Bone produced for World Eating Disorders Action Day. While aspects of the film veer far from reality, the filmmakers are committed to the cause and, to support eating disorder education, they made this PSA which aligns with the best current evidence on eating disorders. Most of the messages I would want viewers of the film to come away with would be covered in this fabulous video. You can also read the Nine Truths About Eating Disorders:

Truth #1: Many people with eating disorders look healthy, yet may be extremely ill.

Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.

Truth #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.

Truth #4: Eating disorders are not choices, but serious biologically influenced illnesses.

Truth #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.

Truth #6: Eating disorders carry an increased risk for both suicide and medical complications.

Truth #7: Genes and environment play important roles in the development of eating disorders.

Truth #8: Genes alone do not predict who will develop eating disorders.

Truth #9: Full recovery from an eating disorder is possible. Early detection and intervention are important.

Produced in collaboration with Dr. Cynthia Bulik, PhD, FAED, who serves as distinguished Professor of Eating Disorders in the School of Medicine at the University of North Carolina at Chapel Hill and Professor of Medical Epidemiology and Biostatistics at the Karolinska Institutet in Stockholm, Sweden. “Nine Truths” is based on Dr. Bulik’s 2014 “9 Eating Disorders Myths Busted” talk at the National Institute of Mental Health Alliance for Research Progress meeting.