To the point: Here’s what parents should know and do about Netflix’s To the Bone

Michael Rich, MD, MPH

The Mediatrician®

Even before the debut of the new Netflix original movie To the Bone, parents and professionals were worried, asking The Mediatrician® about what they need to know — and whether children and teens should watch. The movie, which depicts the story of a young woman’s struggle with anorexia nervosa, has been the subject of many public and private discussions about eating disorders and how they are dealt with in popular culture. Already reeling from the portrayal of suicide in 13 Reasons Why, parents have concerns: Is the film safe for my child to watch? Can it encourage disordered eating behaviors in kids who may be prone to such an illness? Might it upset or trigger a relapse in a child working toward recovery from an eating disorder? Would it present anorexia nervosa as an attention-getting condition that kids and teens might find desirable? The answer to all those questions is “Maybe.” Here’s what you should know and what you can do:

What you should know

• Eating disorders are serious psychiatric conditions that affect a person’s emotional and social well-being and can result in long-term physical problems and even death. They often emerge during the teen and young adult years (but can start in childhood). While these are highly individual illnesses with no single “cause,” factors contributing to risk for eating disorders include genetics and environment (nature and nurture), societal pressures, emotional health, and even certain sports.
• Audience: To the Bone is rated TV-MA (for mature audiences), but has a large tween/teen appeal given the age of the protagonist, the subject matter, and the popularity of its star, Lily Collins. Ratings do little to protect viewers in our “on demand” media environment; a mature rating may even attract aspirational viewers who believe they are mature enough to watch.
• Plot: To the Bone tells the story of a 20-year-old girl named Ellen who has anorexia nervosa. The movie opens with her being released from her fourth inpatient treatment center, not because she has recovered, but because she is rebellious and uncooperative. As she continues to struggle with her illness, we learn about Ellen’s family life, and journey with her as she enters another inpatient care setting that takes a unique approach to treatment, all the while witnessing how her disorder affects her thoughts, her behaviors, her relationships, and her life.

The appeal of the characters — and the misleading messages they convey

Like many movies portraying illness through a single character’s narrative, To the Bone attempts to find the universal in an individual patient. Where the book and movie Girl, Interrupted succeeded with depression, To the Bone falls into well-worn stereotypes. Ellen is a whip-smart, attractive, affluent white girl with a well-intentioned but annoyingly pushy stepmother, absent father, and cloyingly caring lesbian mother. Her fellow patients are charmingly eccentric misfits defined by one-note illness characteristics: the gender-vague male ballet dancer, the tube-fed sweetheart, the binge-eating black girl, the secret purger, and the pregnant teen struggling to eat for her baby. While To the Bone shows what it may look like to live with an eating disorder, it fails to capture the severity of anorexia nervosa. More people die from anorexia nervosa than with any other psychiatric diagnosis.

Ellen is easy to like, especially for teens. She is acerbically funny, brash, and asserts that she is in control… even when she isn’t. Young people struggling with eating disorders can be, and often are, charming, both because they want to feel attractive and to distract others from their illness. But they also feel deep despair, something that is implied but not really shown in To the Bone. Focusing on Ellen’s rebellious “rage against the machine,” To the Bone neglects to reveal the black hole deep inside that fuels her rage. Without showing the self-loathing, hopelessness, and helplessness privately felt by so many struggling with eating disorders, we are left with Ellen’s engagingly moody public persona. For children and teens struggling with eating disorders, body issues, or other life stressors, this can make anorexia nervosa appear to be an attractive lifestyle choice rather than a potentially lethal illness.

Should my child watch it?

The value in watching To the Bone, and other movies and TV shows that portray adolescent health or lifestyle problems, is that it provides a springboard for discussion. It is always easier to discuss difficult issues faced by others (particularly fictional others) than those faced by ourselves. If you decide that taking the risk of triggering your tween or teen is outweighed by the benefit of an open discussion of eating disorders, be sure to co-view To the Bone with her. (Please note that although boys do develop eating disorders, these illnesses are much more prevalent in girls. I will use female pronouns from here forward; substitute “him” and “his” if you are worried about a boy.) A tween (11 to 13 years old) or teen is at a time in her life that is driven by emotion rather than reason. She needs the perspective of your life experience and fully developed executive brain function to process To the Bone with her, to think through the issues rather than reacting emotionally and impulsively.

Ask questions and listen deeply rather than telling her how to respond. Instead of talking points, try asking points:

• How did the movie make you feel?
• What did you think about while watching it? (Name specific scenes to which she responded)
• Could you tell Ellen was unhealthy by the way she looked and acted?
• What did you think of Ellen’s family? Of her doctor?
• What did To the Bone get right? What did it get wrong?
• What behaviors or attitudes may be associated with disordered eating?
• Do you know anyone, friends, classmates, etc., who may be at risk for an eating disorder?
• Who can someone who is struggling go to for help?

Listen to what she says and what she avoids saying, understanding her perspective, thoughts, and feelings. Respond honestly with facts and a caring attitude. She will be wary of being judged. Make it safe for her to talk. Be explicit about your love and support. Be as accurate and complete as you can, acknowledging when you do not know an answer; offer to look it up and think it through together. Learn why being underweight, binge eating (with or without purging), and hyper-exercising are unhealthy. If she is triggered, notify her care team, or you can seek one through the resources below. Talk through how she might seek help for herself or a friend. No matter what she or a friend is going through, reassure her that she doesn’t have to go it alone. You are there for her, and there are caring and understanding medical professionals who can help her find her way to health.

Enjoy your media and use them wisely.

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