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eating disorder treatment

An Eating Disorder Psychologist’s Review of the Film To The Bone

to the bone

To The Bone, a film on Netflix written and directed by Marti Noxon, has sparked a great deal of discussion about eating disorders and eating disorder treatment. Mental health awareness is important, and the film provides a real look into one person’s struggle living with and fighting her eating disorder. There were some aspects of the film that I found helpful and representative of eating disorder treatment, and some things that I wish I saw, or that I believe were underrepresented.

Helpful takeaways from the film:

· It is not productive to place blame. Eating disorders are caused by numerous factors related to complex interactions between one’s biology and environment. Parents cannot cause an eating disorder by staying late at work or getting a divorce. Not only is it not that simple, it is also not helpful to focus on trying to find the exact cause. Instead, it is helpful to address the symptoms that are currently present, and work on complicated family interactions and dynamics.

· Separating the eating disorder from the person is vital. You are not your eating disorder. Dr. Beckham makes this clear when Ellen explains what her eating disorder voice is telling her to do and he says, “f*ck you voice!” While treatment is clearly not this easy, the point that you can separate yourself from your eating disorder is vital in being able to fight it without feeling like you are fighting yourself.

· Enhancing other areas of your life outside of the eating disorder is an essential part of recovery. Dr. Beckham initiates this idea by having Ellen consider if her name really fits with her identity and interests. While it is unconventional to suggest that a client change their name, the point of determining your identity and interests outside of those related to food and eating is important. Eating disorder treatment helps people enhance areas of their life and values that are being neglected or underutilized due to the time and energy the eating disorder has taken away.

· Eating disorder symptoms are not just restricting, binge eating, and/or purging. Numerous disordered eating behaviors are portrayed in the film including body checking, hiding purging, restricting, calorie counting, over exercising, chewing and spitting, and furry hair growth (i.e., lanugo). These are all real signs of an eating disorder, and can often go unnoticed. It is important to note that while many people with eating disorders are experts on calories and nutrition content, as Ellen demonstrated in the film, it is not helpful for friends and family to encourage them to recite this information, as this just fuels the eating disorder.

· Men have eating disorders too. While the film portrays eating disorders as mostly a female issue, there is a male character in the treatment center who suffers from anorexia. Eating disorders are more common in men than many people think. Unfortunately, there is a great deal of stigma around men seeking treatment for eating disorders, which can lead them to suffer in silence. If you are a man with an eating disorder, know that you are not alone, and there are very effective treatments for you.

· It is ultimately up to the person with an eating disorder to be willing to accept help, and there are dire consequences to not getting treatment. This is a tricky one because many people go to treatment unwilling to accept help, unwilling to acknowledge they have a problem, ambivalent about fighting their eating disorder, or terrified of losing control. Often, the initial phase of treatment involves considering what fighting the eating disorder will mean to the person, and highlighting the consequences of keeping it around. The issue is that if someone is significantly underweight, their body might be in “starvation mode,” making it challenging or even impossible to think clearly, flexibly, or about many things outside of food and eating. The effects of starvation mode can be reversed by increasing nutrition intake and gaining weight, which can be terrifying to someone with an eating disorder. If you or someone you know is exhibiting signs of “starvation mode,” there is not enough time to wait for them to be willing to accept help if they are not – it is important to intervene immediately. As indicated in the film, eating disorders can be deadly if not addressed.

· Though it is a lot of work, recovery is possible. There are many myths about eating disorders not being treatable or people having to always live with their disorders. However, though it is not easy, recovery is possible. This is portrayed in the film by Luke, who has been progressing through treatment and seems to be on track to recovery as he works his way up the level system at the treatment center.

· Eating disorder recovery will lead you to live the life you want to live. The point of eating disorder treatment is not just to get rid of your eating issues. Many people wonder what life would be like without their eating disorder, which can be a scary idea. An important part of treatment is determining your values and goals in life and fighting the eating disorder so that you can pursue these dreams and act in line with what’s important to you.

What I wish I saw more of in the film:

· Diversity of diagnosis by race, gender, and age. Eating disorders affect people from many races, cultures, genders, and ages. While the film was meant to depict the experience of one person in particular, it runs the risk of perpetuating the stereotype of a young, Caucasian female with anorexia and an absentee father.

· Family involvement in a constructive way. While there is one family session held in the treatment center, Dr. Beckham seems quick to take them off the table following a challenging session. Family involvement can be crucial in eating disorder recovery, particularly for children, adolescents, and young adults. I wish I saw more urging of Ellen’s father to be present, as well as more sessions with Ellen and her sister to discuss how her sister can be her ally and help Ellen understand the effects of the eating disorder on her family. There is a scene toward the end when Ellen’s mother feeds her like a baby (not a conventional practice in eating disorder treatment), which ends up being helpful in motivating her to return to treatment. However, I wish they portrayed Ellen and her mother working through some of their issues together in treatment.

· Nonjudgmental acknowledgment of self-injurious behavior and its potential co-occurrence with eating disorders. When Ellen arrives at the treatment center, her bag is searched as is standard, and she is asked if she is a “cutter.” This is followed by a judgmental comment about “cutters” being “overachievers.” Self-injurious behavior, like trying to control food intake, is often used as a way to regulate emotions. For instance, sometimes people cut in order to get rid of a negative emotion, and sometimes they cut just to feel something. When self-injury is happening, it is important for the therapist to assess the function and teach skills to help ride out urges and more effectively manage emotions.

· Portrayal of the importance of focusing on food in treatment. While I appreciate many people’s desires not to focus on food in treatment, learning how to eat consistent meals and snacks, and skills for tolerating the discomfort in doing so, are important parts of evidence-based eating disorder treatment. As mentioned earlier, when someone is severely underweight, it is especially important that their weight is restored in order to get their body out of “starvation mode.” It may have been hard for Ellen to make a choice about engaging in treatment or not given her low weight.

If you have or had an eating disorder, I don't need to tell you that this movie will make you think about your own disordered eating behaviors and treatment. I don't think this is necessarily a bad thing, as it provides an opportunity to take stock of the status of your eating disorder and highlights the importance of treatment. I would encourage you to write down your observations and discuss them with your treatment provider.

If you are a teenager or a parent of a teenager with an eating disorder, I strongly recommend discussing the movie, and even watching, together with your parent(s) or teen.

Finally, it is important to remember that To The Bone depicts the story of one person’s eating disorder experience, and everyone is different. There are some helpful takeaways and some things that I wish I saw more of, but overall, I am glad that awareness is being raised about eating disorders and eating disorder treatment.

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