ANDIn the month of June, Netflix released a film titled “To The Bone,” which generated controversy among the community of professionals who deal with these pathologies on a daily basis. It was written and directed by Marti Noxon, based on her own experience with the disease and starring Lily Collins (Ellen). The main character is a 20-year-old girl who suffers from anorexia and underwent various treatments without having obtained favorable results, which is why her stepmother resorts as a last alternative to a clinic in which an “unconventional” treatment was performed, aimed by Dr. William Beckham (Keanu Reeves).
Although eating disorders have existed for a long time, since the middle of the last century their manifestation and prevalence have increased in alarming numbers, affecting various populations and ages (especially adolescents), which makes them one of the paintings with the most social relevance. They are pathologies with high mortality rates, which globally affect the quality of life of the people who suffer from them, as well as that of their families (a situation that can be observed in the film).
The film includes realistic depictions of behavioral, emotional and cognitive manifestations of eating disorders, such as: dietary restriction, dysfunctional compensatory behaviors (such as excessive physical activity, laxative use, vomiting, etc.), erroneous beliefs regarding food and weight, distortion of body image, feelings of anguish, anxiety and low self-esteem, the importance of mass media in the development and maintenance of health and the fundamental role of families.
Although it shows the symptoms, it accounts for the vital risks that the pathology could generate if it is not treated, that is, it tries to promote awareness. Furthermore, one of the positive aspects is that it opens the way to new debates among professionals about approach models and their effectiveness in recovery.
The film includes realistic depictions of behavioral, emotional and cognitive manifestations of eating disorders
However, it generates controversies in the professional community due to the treatment modality shown, in which the patient is expected to seek recovery and be motivated to do so. Personally, I don’t agree. Waiting for the patient to have motivation to carry out the treatment “to make a click, to realize, to seek change”, is like playing with fire, since these disorders are mainly characterized by little or no awareness of the disease (Ellen In one scene he says: “I have it under control, nothing bad is going to happen to me”). So how do you expect someone to want to modify something that they do not see as a problem but as a triumph/achievement? That every kilo you lose generates feelings of satisfaction and mastery?
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There is also the fact that it shows a simplification of a pathology that is so complex, which can basically be observed in two issues:
First, an in-depth diagnostic evaluation was not performed and the treatments were not individually designed. We can see this in the fact that various dishes are served on the table and patients choose based on what is available.
In reality, the treatment is designed based on the nutritional needs and beliefs regarding foods that each of the patients has and their eating style. By knowing which foods the patient considers permitted and prohibited, which generate less or more anxiety, the demonization of foods can be worked on to eradicate false beliefs, in systematic, gradual and sequential exposure to food. Incorporating food but with prior negotiation with patients and not overexposing them to a stimulus as threatening as a table with various dishes of food, which will almost inevitably lead to experiential avoidance. This becomes evident in the film when Ellen and another of the patients, in different situations, got up from the table at lunch/dinner time.
And fundamentally, the fact that they had to eat alone without anyone to check that they actually did so, that they did not hide the food, throw it away or save it, get up from the table without having eaten or purge themselves. The activity of eating requires, at least at the beginning of treatment, to be done in company, the evidence shows this, so that the dysfunctional eating cycle can be interrupted, which is mainly characterized by the avoidance of the experience of eating. Let us not forget that patients with ED do not have awareness of the disease, therefore it will be necessary to structure the context until the patient can acquire functional coping skills and achieve self-regulation.
Being such a complex pathology, it requires that the treatment also be complex. Evidence has shown that basing interventions only on restoring weight and nutritional status and eliminating problem behaviors is not enough; this will be only one of the therapeutic objectives in the initial phase.
Subsequently, efforts will be made to adopt healthy eating habits that can be sustained in the long term, which will be the responsibility of the nutritionist; cognitive interventions on dysfunctional beliefs, psychoeducation regarding the disease and its consequences, on the body and weight standards, exposure, cognitive dissonance, problem-solving training, development of emotional and behavioral self-regulation skills, overcoming the image distorted body and work to achieve a positive image, among others (led by the psychologist).
In the family sessions, we will work on the representation they have of the disease and the sick patient (demystify that everything is due to a matter of will), psychoeducate about the disease (technique that the treatment must go through), identify dysfunctional bonding patterns. and those that could benefit from the treatment, so that they can be worked on. The group sessions will not only be based on the transmission of experiences, but also on the learning of various skills that allow them to have an optimal connection with food, but also skills that promote the improvement of their interpersonal ties.
It would also be optimal for the therapeutic groups to be homogeneous, that is, to be made up of patients with the same personality style or the same pathology, according to the stage of treatment in which they are, such as: psychoeducational, emotional training. or cognitive restructuring, acquisition of problem-solving skills, etc.
If the device is going to consist of hospitalization, it is assumed that it is because outpatient treatments were previously performed and they did not work and the patient needs greater control and attention. This does not happen in the film, since it is observed that there are no controls in the rooms and patios, which is extremely risky (in fact, think about the patient who lost her pregnancy because she continued purging). Additionally, in the film the family members are very little involved in the treatment, when it is considered that their active participation is one of the key factors in the recovery of patients with ED and in the prevention of relapses.
The film “Hasta el Hueso” would alert parents about the real incidence of this pathology and the consequences it generates in the various areas of development of children and adolescents.
In recent years, the scientific community has been especially interested in finding effective modes of intervention with families and obtaining empirical evidence in the approach to eating disorders in adolescents and children. Currently, family involvement has become the first line of choice in treatments, especially in anorexia and bulimia nervosa. This is because it was found that they are families with a more dysfunctional interaction style, compared to patients in a control group. The aim is to find patterns of family functioning that operate as reinforcers of problem behavior to modulate or extinguish them, and to identify those that could be beneficial in the recovery of patients in order to reinforce them. In the case of “To the bone” there is evidence of high emotion expressed by the members, especially the stepmother, the mother and her partner, a lack of cohesion between its members and a lack of empathy.
On a positive note, I highlight that the film instills hope, that is, it conveys that there are possibilities of recovery from this pathology and that there are various possible treatments. Although I do not agree that “unconventional” treatments are shown as alternatives, as defined by their directors, since therapeutic designs should be based on therapies that have empirically proven to be efficient in a certain pathology and population and not on personal beliefs and methods. . In fact, there are studies that show that cognitive behavioral therapy, psychodynamic therapy, and family and group formats have proven to be successful.
Another element that I think is relevant to mention is that throughout the film the importance of group devices is shown, an intervention that I consider fundamental, due to the benefits that sharing with others who, like them, has been shown to generate in patients. , they go through pathology. Currently, the community of professionals dedicated to addressing EDs emphasizes multidimensional treatments, that is, approaches that consider all aspects of the problem (organic, nutritional, psychological), located in the context of relationships. interpersonal (between peers and family) and adapted to the cultural context.
The film would alert parents about the real incidence of this pathology and the consequences it generates in the various areas of development of children and adolescents. It explains the warning signs that could warn that a teenager or child is developing an eating disorder, although I do not fail to highlight that eating pathology is not only inferred from weight and physical appearance, in fact an emaciated state such as the one sample Ellen only occurs in severe cases with a history of chronicity. Therefore, weight should not be considered an exclusive criterion, since a person can be normal or above normal weight and still be suffering from an eating disorder (as is the case with bulimia or binge eating disorder).
It is vitally important to consider emotional, behavioral and cognitive indicators, such as…