Thoughts on “To The Bone”

2017 seems to be the year for controversial Netflix releases – first “13 Reasons Why,” and now “To The Bone.”  Like many other mental health providers, come July 14th, I was prepared to cozy up on my couch and watch the new Netflix movie that promised to tell the tale of a young woman navigating the challenges of anorexia treatment.

I have a lot of thoughts about the “To The Bone” which I will detail below; but first, I want to add the disclaimer that I am speaking to my experience, which likely differs from the experiences of others.  For just over four years, I worked at a well-known eating disorder treatment facility in various levels of care, including Intensive Outpatient (IOP), Partial Hospitalization (PHP), and Residential.  I have never worked inpatient, but have spent time with clients on an inpatient eating disorder unit.  In my outpatient private therapy practice, I focus on the treatment of eating disorders, and have spoken with clients who have participated in various treatment programs across the country.  While I am an eating disorder expert, I certainly do not know everything about every program in the world, or what everyone’s individual experience of an eating disorder is like.  That would be impossible.

Before I go into detail, there is one point that I really want to sink in, whether you choose to continue reading past my spoiler alert below or not.  While “To The Bone” certainly works to break down some stereotypes about eating disorders (e.g. featuring a straight male and women of color as individuals struggling with eating disorders), I believe the film perpetuates the [unfortunate] stereotype that you have to look emaciated to have an eating disorder and to necessitate treatment.  While some of the women in the home are [likely] at a higher weight than Ellen/Eli (the protagonist), the majority are strikingly thin.  Sure, many people who are affected by anorexia and other eating disorders do lose a lot of weight and have that “skin-and-bones” appearance, but here’s why this has my feathers ruffled: Several of my clients have shared that they do not believe they are “sick enough” because they are not “skin-and-bones.”  Or because their eating disorder never landed them in the hospital.  Or because someone didn’t believe them when they reached out for help because they “looked fine.”

You can lose weight and have an eating disorder. You can lose no weight and have an eating disorder. You can gain weight and have an eating disorder.  This is one of the single most important things for people to understand about eating disorders: You cannot tell if someone has one by looking at them; weight does not have to be an indicator (though it can be); in fact, the DSM-V got rid of the specific ideal body weight percentage requirement to be diagnosed with anorexia (Woohoo! Go DSM-V!).  If you have an eating disorder, or disordered eating, or any mental health issue, you deserve help. Period.

Lily Collins, the actress who plays Ellen/Eli, lost weight for this role; she also has a history of an eating disorder in real life.  The energy imbalance that weight loss of any kind requires (even if under medical supervision) heightens the risk of relapse for someone with an eating disorder history.  I have seen this firsthand in my work, and I do not support the decision (though I am unclear who made it) for her to lose weight for this part.  It is also worth noting that her appearance in the movie was likely exaggerated with camera angles, Photoshop, make-up, and possibly mannequins in place of her actual body in some scenes.  This is key for someone who is triggered by her appearance to remember as they watch.

So, as someone who truly hates spoilers, here is where I will insert a big SPOILER ALERT!!! in this post for anyone who has not yet seen the movie.  Granted, it may be helpful to know what you’re in for, but if you want to appreciate the film without knowing plot twists and details, I would stop reading now.  I commend the filmmakers for starting with a warning that the movie may be challenging for viewers, particularly those struggling with eating disorders, or those in recovery.  If you wish to know what specific triggers you may encounter, I have listed them below:

Potential triggers include, but are not limited to: Specific calorie counts, specific weights, emaciated bodies, water-loading, purge behavior, discussion of laxative use, secretive and compulsive exercise, chew & spit behavior, passing out, miscarriage, NG tube, body checking, cutting food into tiny bites, and discarding of challenging foods/components of meals.

One of the biggest criticisms I saw about the film before it was even released was the concern that it “glamorizes” eating disorders.  This was, I assume, based on the trailer, released several weeks before the film became available.  The trailer shows a group of patients, both male and female, living in a cozy, well-decorated home, working on recovery together.

My take away? I do not feel the film glamorizes eating disorders, per se, but perhaps does not accurately portray what a typical treatment center experience is like.  To be fair, they do refer to the doctor (played by Keanu Reeves) as having “unusual methods.” That being said, I think I owe it to readers to explain how a typical treatment facility works (again, based on my experience in the field):

Many Residential programs are quite nice, possibly in a well-kept home (as in the film), or in apartment-style living.  During mealtimes, patients generally come together and eat as a group.  Depending on the program and the age group of the patients, food is either prepped by the patients themselves, or by a chef or counselor in the program.  There are generally one or more staff members sitting with the group to provide support if a patient is struggling, and to redirect eating disorder behaviors (many of which are evidenced in the film) or topics that may be triggering at mealtimes (e.g. calories, comments about food, weight, etc).  It is unlikely that patients would be eating without staff support, or that they would not be expected/encouraged to eat during a meal, as portrayed in the film.  It is also unlikely that they would be able to choose their own food, and eat just hard-boiled eggs, or peanut butter, or a candy bar for a meal; meals are generally balanced containing components from each food group.  If a meal or snack is not completed, the patient would likely be coached individually by staff, and ultimately offered a supplement (such as Ensure or Boost), or possibly a nasogastric (NG) (i.e: feeding) tube if they were not properly nourished.

In “To The Bone,” the program is referred to as an inpatient unit, which is confusing, as an inpatient facility is generally more like a hospital, and less like a group home.

So, back to the idea of whether or not the film glamorizes EDs: Ellen/Eli had to drop out of college due to her eating disorder.  She has been inpatient several times, and many of her housemates share that this is true for them, too.  One of the women is 12 weeks pregnant and suffers a miscarriage, which is assumed to be related to using eating disorder behaviors such as restricting and purging, as compromised fertility is one of the many serious side effects of eating disorders.  Ellen/Eli’s sister speaks about how she does not get to have the full experience of having a sister due to the eating disorder. Ellen/Eli has lanugo (excess body hair grown to keep her warm due to not having enough body fat) on her arms, passes out at a train station, has bruises along her spine, and is constantly cold.  She is near death by the end of (and presumably throughout) the movie.  All of these things – multiple admissions, serious medical consequences, family issues – are very real when it comes to eating disorders, and I, as well as many of my clients who have discussed the film in sessions, do not feel this glamorizes the illness.  In fact, I am glad it shows so accurately how much an eating disorder can suck the life out of someone – both physically and mentally.  (That being said, if you have not experienced any of these specific consequences, you are still deserving of help.)

Going back to how treatment is not necessarily accurately portrayed in the movie, let’s talk about that bottle scene.  This was a significant topic of conversation with many of my clients afterward.  Toward the end of the film, Ellen/Eli’s mother begins to lose hope about her daughter’s ability to recover given the long, arduous road they have been down since the onset of her eating disorder.  One day, her mother has a premonition that tells her she should feed her daughter the way she did when she was a baby, and she encourages her daughter to try this approach.  Initially, Ellen/Eli says ‘No way,’ but shortly thereafter, she comes around and allows her mom to feed her … sitting in her lap and drinking rice milk from a baby bottle.  This is definitely unexpected, and certainly not a typical form of treatment.  Methods like the Family-Based Treatment (FBT) approach, also known as Maudsley, focus on the parents temporarily taking over food preparation in order to renourish their sick child, but certainly not in the way that is shown in the film. In fact, some of the teens I work with were quick to say they were concerned that peers of theirs watching the film might think that’s what their ED treatment was like. I was initially a mixture of both shocked and a bit uncomfortable watching this scene, and it was actually my husband who provided some great empathy for the characters, commenting that most parents would do anything they could think of, even if strange or unconventional, to help their sick, dying child.  I thought he offered an interesting perspective on an otherwise unusual scene.

I loved some of Ellen/Eli’s therapist’s quotes, such as “What you crave is the numbing of the thing you don’t want to feel,” “Feel the fear and do it anyway,” and “Bad things are going to happen, that’s non-negotiable; what is [negotiable] is how you deal with it.”  Eating disorders are often about pushing away uncomfortable emotions by using disordered behaviors (e.g. when Ellen/Eli does sit-ups in her bed after a particularly emotionally challenging day), and often recovery is about confronting and sitting with these emotions.  He also says during a family therapy session that “Fault and blame have no place here,” which is so consistent with the Family-Based Treatment (FBT) approach, and can help families move forward in treatment.

I thought the movie did a nice job showing how the house members could be supportive of one another through their eating challenges at meals, even though they were struggling themselves.  That being said, I did not like the storyline about Luke and Ellen/Eli falling for each other, as relationships formed in treatment can often create challenges regarding recovery, particularly when they are romantic relationships.  At one point, Luke asks Ellen/Eli to stay in the home because he “needs” her, given his fear that he may relapse after learning some bad news.  People need to make decisions for themselves, and not feel guilted into being there to assist in someone else’s recovery.  It is okay to focus on yourself during treatment; in fact, you will be better at helping others (eventually, if you so choose) if you have first given yourself the time and attention you deserve.

I wish the film had shown successful treatment – while still acknowledging that it may take several admissions – to give hope that recovery is possible.  I wish it had not ended with the idea that you have to hit “rock bottom” in order to recover; for many people, hitting rock bottom can be fatal, which is a gamble that is not worth taking.

I found myself wondering what the purpose/goal of the film was.  Was the goal to show what it is like to have anorexia?  To that, I would say that while Ellen/Eli’s experience certainly may be relatable for many people, the film runs the risk of being incredibly triggering due to the use of specific numbers/behaviors (as listed above), and featuring someone so visibly underweight.  I also wondered if it might turn viewers off to treatment if they hadn’t yet sought it, believing that they would not be able to receive proper support, particularly at meals, while living in a home with other patients.

If you have not yet watched the movie, I hope this helps guide whether you choose to watch, and helps inform you about potential challenges the movie may bring up.  If you have watched it and are feeling triggered or emotional, or just want to process it, I would encourage you to reach out to someone you trust when it comes to discussing eating disorders – a friend, family member, therapist, dietitian, or doctor.  Support is out there.  Remember that you are not alone in this illness, and although recovery can be incredibly challenging, it is absolutely possible.

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