TV & Movies

What Doctors Want You to Know Before Watching To the Bone

This is a must-read for anyone planning on viewing the highly controversial flick about a young woman's struggle with anorexia

Psychiatrists voice concern over To the Bone, image shows actress Lily Collins' profile faded in the back to grey with a purple border and a purple prescription pad at the bottom

To the Bone, the already much-debated Netflix film which follows a 20-year-old woman and her ongoing struggle with anorexia, begins streaming on July 14, and many eating disorders specialists advise that it be viewed with caution—if at all.

The film, which stars Lily Collins, has prompted heated debate about how to portray eating disorders in a way that isn’t harmful to survivors or those struggling with, or susceptible to, an eating disorder—or whether that is even possible. After the trailer was released, social media users immediately began sharing their views, some accusing the film of glamorizing eating disorders and others arguing that the movie will begin much-needed conversations about these diseases.

A 2014 report revealed that an estimated 600,000 to 990,000 Canadians may be dealing with an eating disorder; the most common conditions being anorexia nervosa, bulimia nervosa and binge eating disorder. Anorexia nervosa, the focus of To the Bone, has the highest mortality rate of any mental illness, according to the National Eating Disorder Information Centre (NEDIC).

Before clicking “play,” we asked two Canadian psychiatrists who specialize in eating disorders what you need to know.

Takeaways from the trailer

Like most psychiatrists, Toronto eating disorder expert Dr. Allan S. Kaplan is wary of speculating about the overall impact of To the Bone simply based on a two-minute clip. He points out that there have been many films about anorexia, and the main concern he has is their tendency to stick to the “Hollywood script with a happy ending.”

“Such movies romanticize and trivialize the illness, do not present it as a  psychiatric illness, which it is, and underemphasize just how serous anorexia nervosa is,” says Kaplan, who has been treating eating disorder patients for more than 30 years. “I realize that in order to make it marketable, it needs to have entertainment value, but the film will do a disservice to those sufferers and their families if it is presented in a way other than as a serious, devastating, potentially life-threatening illness that robs young people of their physical and emotional well-being. There is nothing humorous about it.”

Why the film could be “triggering”—and what that means

It seems like every tweet and article about To the Bone discusses the risk of this film being “triggering” for those with eating disorders, or those vulnerable to developing these types of conditions.

“Anorexia is almost always a genetic disorder that’s precipitated by weight loss, and perhaps a stress, and it causes an aversion pathway in the brain,” explains Dr. Laird Birmingham, a Vancouver-based psychiatrist and eating disorder specialist. “It’s sort of like a phobia of, for instance, heights, but in this case, it’s a phobia of getting fat. Once that starts, it’s present to a certain degree for the rest of one’s life.”

Birmingham explains that when someone with a history of eating disorders sees the type of images in the To the Bone trailer, such as an extremely thin Lily Collins adding up the calories on her plate, it can prompt a subconscious reaction that reignites—or “triggers”—their fear of gaining weight. Both Birmingham and Kaplan highlight the fact that most anorexia nervosa patients do not recover fully; researchers estimate that 40 percent of patients relapse within their first year of recovery.

Why the film could be educational in the *wrong* way

Experts and social media users also called out To the Bone for its potential to teach people with eating disorders different methods for avoiding food.

Birmingham explains that when patients enter group treatment programs, they often learn new tactics for losing weight (or ways to conceal their disorder) from other patients. Films like To the Bone can run a similar risk.

“The vast majority of people I’ve seen over the last 40 years have learned about eating disorders through other people or through experiences like reading a book or seeing a movie,” he says, adding that he is concerned that viewers may idealize Collins and her weight loss.

Why it’s super problematic that Lily Collins lost weight for the film

Actors Lily Collins, wearing a hospital gown, and Keanu Reeves in a doctor's office

(Photo: Gilles Mingasson/Netflix)

In the trailer for To the Bone, Collins appears extremely thin and she has publicly stated that despite her history with anorexia, she “safely” lost weight for the film under the supervision of professionals. American eating disorder organization Project Heal, which partnered with the film to ensure that the content was accurately and carefully presented, stated that they do not support the fact that Collins lost weight for this role.

“There is strong research showing that getting into a state of negative energy balance and/or losing weight can make people who have struggled with anorexia nervosa much more prone to a relapse,” Project Heal stated on its website. “The weight loss aspect is not something that Project HEAL supports.”

Birmingham agrees and says that even though makeup, wardrobe, a body double and special effects were used to enhance the actress’s appearance, having someone with a history of eating disorders intentionally lose a lot of weight is a dangerous thing to do—and sends the wrong message to viewers and fans.

“It’s like someone with cancer getting a little bit of cancer again to make a movie,” he says. “That would be ridiculous, no one would ever do that.”

The need for trigger warnings

As was the case with 13 Reasons Why, critics quickly pointed out the lack of viewer warning before the To the Bone trailer. (Note: Due to the controversy, 13 Reasons Why later added warnings and reworded existing messaging). Birmingham and Kaplan agree.

“The images of an emaciated young woman can certainly be triggering for both current sufferers and vulnerable young women. The warning should also include a statement that although the actress who plays the lead had anorexia nervosa as teenager and had to lose weight for the role, it would be very dangerous for someone in recovery from anorexia nervosa to pursue weight loss again for any reason,” says Kaplan.

Birmingham adds that the warning should recommend that people who have had eating disorders or who are vulnerable to such conditions should avoid watching the film altogether. While these messages won’t necessarily prevent people from watching, he argues that at least if there is a warning, viewers will be somewhat prepared for scenes—like the one of a very thin Collins overexercising–that they’re about to see.

What you need to know before viewing, whether you’ve been affected by an eating disorder or not

Birmingham’s message for people with a history of eating disorders is: “There are eating disorder experts that believe that this [film] could cause a relapse or precipitate an eating disorder and therefore viewers should be talking to someone after they see the film.” Ideally, that “someone” should be a healthcare professional or organization such as the National Eating Disorder Information Centre.

Experts say that those who have not had direct experience with eating disorders also need to view with caution.

“Most people believe that eating disorders are a choice and I hope that it comes across in the movie that it’s not a choice, it’s a disease,” says Birmingham. “If they think that the information they can get from the film can help people with eating disorders or counsel them or prevent eating disorders, then that’s dangerous.”

If you or someone you know is struggling with an eating disorder, we encourage you to reach out to the National Eating Disorder Information Centre helpline at 416-340-4156 (GTA) or 1-866-633-4220 (toll-free). Trained support workers are available Monday to Friday, from 9:00 a.m. to 9:00 p.m. EST and can offer resources and referrals to eating disorders specialists across Canada.

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