To The Bone (yes, netflix does it again)

Last night, I settled in with my large hot chocolate on the couch to watch the movie on eating disorders - “To The Bone”. 

For those of you who haven’t seen the shorts – this is a movie about a young woman with anorexia who gets treatment for an eating disorder.  She has a short stay in a group home facility, meets others with eating disorders, has some family therapy, a short romantic relationship with another person with an eating disorder and ponders whether she really does want to get “better” and overcome her eating disorder.

Along with many of you - I've worked with many kids/teens with symptoms of disordered eating and struggles with body image for many years - so I was keen to see whether this was going to be a useful movie I could recommend to families.

Unfortunately, I don’t think it is. 

But as usual when it comes to these kinds of issues, I have mixed feelings.  Here are my thoughts.

Here are the four aspects of this movie I like.

1. The movie will raise awareness of the existence and nature of eating disorders.  This is probably a good thing.  Although as professionals working with young people we are often (or constantly - depending on your role) - exposed to eating and weight related problems - society in general doesn't get a lot of exposure to this problem.  Movies like this therefore may be helpful in that people with an eating disorder may watch and feel comforted to be reminded they are not alone.  Those in the general community may learn about these disorders and feel compassion for those who suffer. 

However, while awareness is important - we should keep in mind that only about 2% of children and teens develop an eating disorder during their childhood/adolescence in this country.  While eating disorders are a problem for society as whole (and probably under-reported because of the shame and lack of motivation for some sufferers to go into what is usually a painful and difficult treatment) – they are not as common as anxiety or depression in young people.  I make this point because sometimes movies like these mean we start over-stating the prevalence of these disorders which I think is also unhelpful – and may even normalize something which is still uncommon.

2.      The movie shows some of the problems and suffering experienced by those with an eating disorder

The main character looks drawn and haggard (more on this in a minute), with excessive body hair, fainting episodes, talks about being hungry and is sometimes anxious and distressed.  The movie doesn’t shy away from the fact that eating disorders are painful.

3.      The movie also clearly shows how distressing an eating disorder can be for family members. 

The very real struggle for families with a family member with an eating disorder is not widely understood.  I liked that the movie made family suffering a prominent part of the character’s story.

4.      The movie also shows that treatment is available and can be effective. 

In the movie, several of the characters in the group therapy home seem to be improving which provides a positive message about eating disorder treatment.  I’m pleased about this – this could be life saving for those with eating disorders who haven’t yet sought treatment.   This is especially important because people with eating disorders often don’t get treatment quickly – there is an average of four years between the emergence of eating problems and first sessions of therapy.  And the longer people delay getting treatment, the less successful treatment is likely to be. 

On the flip side however, the only people getting treatment in this movie are those who are particularly sick.  I felt like this could suggest  that you need to be severely unwell before you can get help – which of course could be a particularly dangerous message for some young people who don’t think they are “sick enough” and need to get worse first.

So, all good then?  Should we start showing this movie in schools?  Suggesting families we work with see this movie?

No.  Unfortunately alongside these positive messages, the movie also contains some unfortunate messages and some unhelpful content. 

Here are five big problems with this movie.

 1. The movies clearly outlines some of the “methods” of eating disorders

You could learn a lot from how to develop an eating disorder from this movie if you were so inclined.  For example the house group members share tips and tricks to continue to lose weight/binge/purge secretly even while in treatment and the main character is repeatedly shown to use a range of strategies to maintain her disorder.   There is a real risk that some young people could use this movie as somewhat of a “how to” in eating disorders.

2. The key character with an eating disorder in the movie is funny, engaging, charismatic, talented and – despite looking sick – still conventionally attractive.   

Of course it’s not a crime to be any of these things (and what was I expecting with a Hollywood movie) but I can’t help but wish the main character had been older/less conventionally beautiful/with less obvious talent and maybe slightly more annoying.  Young people are desperate to be liked, cared for, admired and talented.  I wouldn’t be at all surprised to discover that many teens have watched this and feel envious and aspire to be like her.

3. It doesn't show the extent of the usual kind of suffering experienced by those with an eating disorders. 

Eating disorders are devastating and life destroying (for example, they have the highest mortality rate of any psychiatric disorder).  The character in the movie does look troubled at times, but throughout the movie she is often happy and making jokes.  She rarely seems as depressed and socially isolated as most of the young people with eating disorders I’ve come into contact with.  It's a particular shame that the social isolation and conflict often experience by young women with eating disorders is not highlighted - as in my experience sometimes these are powerful motivators for young people to get treatment/work hard at treatment.

4. It doesn't show what's involved in effective treatment.

In the movie, treatment appears to involve some cosy chats with Keanu Reeves (the strong, single, very attractive and very cool male therapist role model – not exactly representative of the kind of psychologists usually involved in eating disorder treatment 😊), living in a “party of five” type of fun house with a lot of peer support, some group meals where everyone chooses what to eat (this is unconvential for typical eating disorder treatment) and a very unsettling bottle feeding routine between the character and her mum towards the end of the movie. 

This is not representative of the kind of evidence based treatment for eating disorders, which suggests that family based, cognitive behavioural therapy – over many sessions – is most useful.  Also, from my experience, eating disorder treatment involves enduring a lot more tears, anger, panic, guilt and even feelings of disgust for most people.

So in conclusion – I can see four positive messages, and four unhelpful ones. 

However - given the potential danger in exposing young people to these unhelpful messages in this movie, I’d rather young people didn’t watch it. 

I believe that for some kids and teens who either have or who are at risk of developing an eating disorder, it could quite feasibly trigger jealousy, anxiety about current weight, desire for weight loss and disordered eating behaviour.

What’s the solution?

Although I’d rather this movie have not been made in the way it has, given that it has – we need to deal with it.  I’m not a fan of banning movies altogether for teenagers. 

What should we say to parents if they ask us?

The outright “no, you can’t watch it” might be appropriate for younger children.  I am saying to parents - if your younger child asks to watch it, and think you it’s unlikely they will be able to sneak onto Netflix later – say no.  Don’t forget to use this as an opportunity to talk with them about the issue however. 

I suggest to parents and caregivers they might say something like this:

“This movie is for adults and older teens.  It has some ideas in it which are upsetting and might make you feel worried about adult stuff.  If you still want to watch it in a year or two, we can do together.  Let’s watch X together instead”

I think we need to empower parents to "take charge" and prevent viewing for some younger adolescents.  An important message from us as professionals is that - just because "everyone else" is watching it, doesn't mean they have to let their young people.  Sometimes parents need to hear this from us, it gives them permission to do something they feel is the right thing to do.  I often tell parents/caregivers about other families I know who are putting this particular rule in place - there is something about the power of social norms which gives them the courage to do the same.

Having said all of this, there is no point parents/caregivers "banning" the movie for a teen who then goes and watches in on their phone.  If this happens the problem is exacerbated by secrecy, guilt and loss of conversation opportunity.  Here's what I am saying to parents about this:

"However if your older child – for example a 16 year plus teenager -  wants to watch it and can’t be distracted by another suggestion, ask them if you can watch it together and talk about it afterwards."

I am also providing them with some ideas about questions to ask (as always, being as specific as possible with parents about exactly what words they might consider using seems to help them be able to broad these conversations).  Here are some question ideas for parents/caregivers I've come up with - I'm sure you have some of your own.

How often do teens want to be thinner?
What’s the difference between wanting to be thin and an eating disorder – do you know?
How often do teens feel really anxious about food? Their weight?
How about you?
How realistic do you think this movie is?  In what way is it realistic/unrealistic?
I think there are probably a few different things which cause eating disorders – do you have any ideas about some of the causes?

Do you think the way we think about appearances in our society plays a part in causing eating disorders?

Do you think eating disorders are more like an addiction – or more like a anxiety problem?

Have you ever felt a bit like the character in the movie?

What would you do if you starting to feel like the character in the movie?

There are no right or wrong answers to these questions – but it will help you identify whether there are any risks you need to monitor, and help encourage your teenager to talk with you about their opinions and thoughts.

Here are some ideas about things to say:

I’ve read that this doesn’t accurately show what it’s like to have an eating disorder.  It seems like it’s a lot more complex, and much more painful than what this shows.

I like that it shows that there is treatment.  I don’t think this is the kind of treatment that is used here in Australia.
I would worry that it seems like there is something exciting or interesting about having this disorder.

I would hate you to ever get into that kind of cycle.  I know it would be pretty easy for it to start – it’s so addictive for some people to lose weight/throw up/not eat/exercise too much.  Because it’s really easy to get stuck into it, I’m going to do what I can to make sure you don’t get stuck in that cycle,

What else can we do as professionals?

Of course, we should also be asking questions and providing an alternative perspective if we are involved in conversations with young people about this movie.

We also need to get into the habit of "screening" for eating disorders in young people.  Particularly keep an eye on young people with perfectionistic traits and high levels of anxiety (shown to be associated with eating disorders)

Most of them are not getting help quickly, and hide the problem for a long time. Interestingly, some research suggests that most young people with an ED do actually talk with professionals prior to starting treatment but talk about other problems - health problems, anxiety and depression and other areas of concern.  This same research suggest that while young people frequently don't volunteer information about their disordered eating - they actually would welcome questions about it, given the level of suffering they are often experiencing.

A group of researchers in 2003 (Cotton, Bell, Robinson) found that the two best screening questions for eating problems were:  Does your weight affect the way you feel about yourself? and "Are you satisfied with your eating patterns".  We might have to modify these for younger kids, but this is a good start.

In terms of treatment, research suggests that family based treatment is superior to individual treatment for young people - so it's important that we are involving family as soon as possible.  And given the risks to safety which exist for young people with eating disorders, I believe this often means we need to consider breaking confidentiality when a young person confides in us about disordered eating behaviours.  Obviously we need to tread carefully here, but eating disorders are not something to be taken lightly.