Christine M. Peat, PhD (Assistant Professor at CEED), Ruchita Bhatia (a rising junior at UNC Chapel Hill) and Cynthia Bulik, PhD (founding director of CEED) independently viewed and reviewed the newly released Netflix movie To The Bone and gave grades on how well the movie reflected the Academy for Eating Disorders Nine Truths. Inter-rater reliability was pretty high!
Truth #1: Many people with eating disorders look healthy, yet may be extremely ill.
Peat/Bhatia: B. Although Ellen fits the very thin stereotype of anorexia nervosa, many of the other characters depicted in the movie, who also suffered from anorexia nervosa or bulimia nervosa, are within the bounds of what appears to be a normal BMI. Thus, only a small proportion of fit the stereotypical “ill” presentation of those with anorexia nervosa. Notably, there is a scene that illustrates that appearance does not equate health status when Ellen blurts out, “I don’t feel that unhealthy…I’ll outlive the normies,” which illustrates that individuals with eating disorders may not “look sick,” but are still dealing with potentially life-threatening illnesses.
Bulik: B. Although many of the patients in the film conform to the low weight anorexia nervosa stereotype, they did include some individuals who were at different body weights, shapes, and sizes.
Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.
Peat/Bhatia: C. Throughout the film there is an emphasis on the family dynamic that may inadvertently lead the audience to believe that families cause eating disorders. Ellen’s family members are portrayed as toxic, chaotic, and argumentative, and these scenes are juxtaposed with her in treatment and/or while struggling to eat. Collectively, this might lead one to believe that these family experiences “caused” Ellen’s illness. Encouragingly, Ellen’s physician did note that, “There is never one cause,” and as the film progressed, Ellen does receive support from many of the characters (e.g., her sister, her biological mother, Luke), demonstrating the incredible power of families/loved ones as allies in treatment. However, these messages are brief and are overshadowed by way the family dynamic is depicted throughout the film.
Bulik: C. The film insinuated throughout that a dysfunctional family is the root cause of anorexia nervosa. In a rather twisted way (with the baby bottle), they do portray that families can be allies in treatment, but not in a way that any provider that I know would advocate. Ellen’s strongest ally is her sister. In fact, I think their relationship is the most genuine in the film. Her sister sticks by her even when she makes decisions that are antithetical to recovery, but she is not just a passive support. She lets Ellen know how it makes her feel and pushes for recovery. We know from our work with couples that this active encouragement and expectation of change is important. My favorite line in the movie is when the sister says, “If you die, I’ll kill you!” which nicely illustrates the desperation and fear that siblings feel as well as the freedom they have to say such things.
Truth #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.
Peat/Bhatia: A. This film does illustrate well how disruptive having an eating disorder can be in a family and personal life. The family meeting with Dr. Beckham helps to depict this by demonstrating the disruption in Ellen’s personal life as well as those of her family members including her mother, step-mother, and sister. During the family meeting Ellen’s sister expresses how painful and upset she is that Ellen’s eating disorder also affects her own life. Throughout the film it is clear how isolated Ellen becomes as a result of her eating disorder and how it negatively impacts on her mood and decision making.
Bulik: A-. The film does show the devastating effect that anorexia nervosa can have on the family. The profound ripple effects on both of her families are clearly evident, but unfortunately, not dealt with therapeutically adequately in the film. Then again, nothing is really dealt with therapeutically in the film! In fact, the doctor often sides with the patient in criticizing her family, “Does she always talk that much?” (about the stepmother) and telling Ellen that her name doesn’t suit her and encouraging her to change it (basically insulting her parents’ choice of name).
Truth #4: Eating disorders are not choices, but serious biologically influenced illnesses.
Peat/Bhatia: F. To the Bone represents Ellen’s eating disorder as a choice. It does little to highlight that Ellen’s situation is a unique combination of both genes and environment. There is no mention of the extent to which eating disorders are genetically influenced, and this lack of information reinforces the myth that people choose to have an eating disorder. Such a myth is harmful not only to those who struggle with eating disorders, but also to the general public who might then dismiss these life-threatening illnesses as vain and/or superficial.
Bulik: D. Sadly, the biological nature of eating disorders is not conveyed adequately at all. In contrast, there is more of a focus on trauma history, family dynamics, and childhood experiences. (Note: I applaud Christine and Ruchita’s boldness in giving this an F grade!)
Truth #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.
Peat/Bhatia: C. This film mostly represents those with eating disorders as young, female, Caucasian, and with body sizes that are thin and/or underweight. Although the film does include an African-American woman and a male with eating disorders, the majority of individuals depicted represent only a narrow slice of the demographic who are diagnosed. This lack of diversity in terms of race, ethnicity, age, and body shape reinforces inaccurate stereotypes of those with eating disorders. A substantial literature exists that demonstrates that eating disorders do not discriminate based on any demographic characteristic and it is time for media portrayals to reflect this truth.
Bulik: B. The film at least makes an effort to show diversity in those who were portrayed as suffering from an eating disorder by including individuals suffering from several illnesses (anorexia nervosa, bulimia nervosa, binge-eating disorder), both white and African American (could have used more diversity here but with a fairly small cast it would be hard to portray the full range of individuals afflicted), a male with anorexia nervosa, heterosexual and homosexual individuals, and a range of ages including someone who was pregnant (which I really appreciated because it is often overlooked and assumed not to happen!).
Truth #6: Eating disorders carry an increased risk for both suicide and medical complications.
Peat/Bhatia: C. The film graphically depicts the medical complications of eating disorders including: Ellen’s very thin frame, the bruising she incurs from sit-ups, lanugo she develops from low weight, and the spontaneous abortion Megan experienced during treatment. In doing so, To the Bone does a good job of portraying some of the medical complications that can occur; however, these medical complications are not exhaustive. Additionally, the filmmakers did not accurately represent the serious risk for suicide inherent in eating disorders. The literature suggests that individuals with eating disorders are at high risk for suicide; however, the film does not discuss this risk or discuss the importance of addressing this as a part of treatment.
Bulik: C-. Some medical complications were portrayed such as Luke’s knee (although it was unclear if that was a consequence of anorexia nervosa or a trigger for the development of the illness), Ellen’s lanugo hair, and the miscarriage. There are allusions to being fatal, but really not much discussion of either suicide or medical complications beyond that. Importantly, the doctor’s comment about the importance of letting people with anorexia hit rock bottom is counterproductive and frankly dangerous. The problem with letting someone with anorexia hit rock bottom, is that they can die.
Truth #7: Genes and environment play important roles in the development of eating disorders.
Peat/Bhatia: C. This movie does discuss Ellen’s social and physical environment; however, it does not capture the aspect of biological influence. Overall, there is an overemphasis on the environmental role on eating disorder development.
Bulik: D. With the exception of Ellen’s biological mom having post-partum depression, there is really no talk of genetic factors at all. The film focused strongly on environmental factors.
Truth #8: Genes alone do not predict who will develop eating disorders.
Peat/Bhatia: B. As mentioned above, there is a significant emphasis on the environmental influences on eating disorder development. Therefore, the viewer can certainly walk away from the film appreciating that it is not biology alone that predicts eating disorder development; however, the complete lack of information on the genetics of eating disorders means that a crucial component of the equation was missing.
Bulik: C. They had the environmental part covered, but focused primarily on the effects of unwanted sexual attention as a trigger for Ellen’s anorexia nervosa.
Truth #9: Full recovery from an eating disorder is possible. Early detection and intervention are important.
Peat/Bhatia: C. Although the film demonstrates that recovery results from a process of many factors, it is limited in its depiction of treatment and detection. The treatment shown in the movie represents only a small proportion of individuals seeking treatment for an eating disorder. Many work with their treatment teams on an outpatient basis, many are working in college counseling centers, and food/dietary plans are typically a significant component of treatment. In addition, the simulated feeding that Ellen and her mother practice at the end of the movie is not an evidence-based practice. Therefore, while many of the patients in the movie display a determination to recover, the treatment methods depicted re narrow and unrelated to the evidence base. The movie also does not depict how individuals recover from an eating disorder, but rather suggests that someone can simply choose to recover after (perhaps) a life-altering event. The reality, however, is that recovery is incredibly hard work in the part of the individual and often involves years’ worth of treatment.
Bulik: B-. They did a fair job of conveying the fact that recovery is hard, but it can happen. Unfortunately, they made no effort to convey the importance of evidence based treatment. They dissed Maudsley (Family-Based Treatment) within the first 12 minutes of the movie and took the Renfrew Center down with it. The message that only unconventional treatments and renegade doctors are effective is not helpful to individuals with eating disorders or their loved ones. To anyone out there who is seeking treatment for themselves or a family member—this is not what you should be looking for!
Peat: C. The movie does represent some accurate features of eating disorders and their treatment. Many individuals with eating disorders are extremely thin, require inpatient hospitalization, and can pinpoint environmental triggers (e.g., family conflict, history of abuse). However, overall, this film often plays into stereotypes of eating disorders including a lack of diversity, representing eating disorders as choices, and not including information on the importance of biology in their causes. Thus, although this film might accurately represent some individuals’ experiences, for those with different experiences and for audiences who might be otherwise uneducated, there was a major missed opportunity to correct myths and highlight the truth of eating disorders and their treatment.
Bhatia: C. This movie does depict an artistic story about a girl’s quest to live. While it does capture many of the important points about eating disorders, it lacks more scientific backing. I felt this movie will contribute to removing taboos from talking about eating disorders and will stir many conversations within the community. That is certainly a great step in the right direction!
Bulik: C. To The Bone was realistic in many ways and may well accurately portray the director’s experience of anorexia nervosa. I almost stopped watching at the baby bottle scene, which seemed like Hollywood over-dramatization and sent a bizarre message about recovery. Yes, parents need to feed their children, but not in a regressive way that allegedly corrects some early attachment problems. Although I have been reassured that there were cinematographic tricks used to make Lily Collins look so emaciated, I do remain horrified that someone with a history of the illness was placed in dangerous negative energy balance for the sake of art. My deepest disappointment—aside from not mentioning genetic contributions to eating disorders—was the absence of any portrayal of how evidence-based treatment can aid in recovery. I reminded myself that it was not a documentary, but the familiar plot of an unconventional rebel doctor who has issues of his own but is dedicated to his work, raises false hopes and doomed searches for quacks who are playing with fire.