In the recent Netflix movie “To the Bone” ― a clear-eyed story of a young woman’s struggle with anorexia nervosa, based on the real-life experiences of writer/director Marti Noxon ― there is one particularly controversial scene.
Main character Ellen, played by Lilly Collins, is cradled in her mother’s lap while her mother, Judy, bottle-feeds her as if she were an infant. Judy, played by Lili Taylor, says she didn’t hold Ellen enough when she was an infant, and wonders if this is what caused Ellen’s eating disorder. The “bottle-feeding” intervention is Judy’s attempt to “re-nurture” her daughter.
After watching this part of the movie, Bridget Whitlow, a psychotherapist and specialist in eating disorders, had a strong reaction.
“I’m not aware of any therapists who practice bottle-feeding therapy,” she says. “It’s definitely not a scientifically proven treatment for eating disorders.”
Bottle-feeding therapy is a controversial form of treatment in the world of eating disorders. It suggests that a fractured mother-child bond causes disordered eating, effectively blaming moms for their children’s mental illness. But research shows that multiple factors ― genetics; family dynamics; perfectionism; even other mental health conditions, like obsessive-compulsive disorder ― can all play a role in someone developing anorexia nervosa.
“Many variables contribute to the development of eating disorders, including biological and psychological factors,” says Ilene Fishman, a clinical social worker and co-founder of the National Eating Disorders Association.
Noxon told USA Today that the bottle-feeding method didn't actually help her, when her own mother -- "a hippy-dippy alternative medicine fan," in Noxon's words -- tried it on her when she was 16. "It was incredibly awkward," she told the newspaper. "We never did it again."
Still, the idea of bottle-feeding therapy has demonstrated a certain staying power. And that might be because it centers, correctly, on a couple of phenomena that make anorexia nervosa and other eating disorders hard to treat ― and that aren’t addressed by most current forms of therapy.
Attachment issues do often underlie an eating disorder
Whitlow says the bottle-feeding approach most likely stems from a psychoanalytic concept called attachment theory.
In the 1960s, the psychologist John Bowlby popularized the notion that healthy psychological development depends on a child’s ability to securely attach to a caregiver, usually the mother. But while attachment theory explains aspects of child development and how we form relationships, it’s not a popular theoretical lens for understanding eating disorders.
Dr. Kelsey Latimer, a clinical psychologist and assistant director of East Coast outpatient programs at the Center for Discovery, says that “while ‘bottle feeding’ is not an intervention I’ve used with my patients, it illuminates the deep attachment wounds that can underlie the development of an eating disorder.”
Trauma contributes to many psychological problems, including post-traumatic stress disorder, anxiety, and depression. Attachment-specific trauma, however, is a response to a catastrophe like childhood abuse or neglect, emotional abuse, or the death of a caregiver or loved one.
Hilary Jacobs Hendel, a psychotherapist and trauma expert based in New York City, believes that disrupted attachment contributes to psychological suffering.
“When people were not properly held as infants, their ability to regulate emotions is compromised,” Hendel says. “The eating disorder becomes a way to manage upsetting feelings.” She also believes that eating disorders can be symptoms of attachment traumas, signs that a caregiver wasn’t able to soothe their child.
While Hendel doesn’t use the bottle-feeding intervention, she will occasionally wrap a patient in a blanket, helping to calm their nervous system.
“This can make it easier for them to process emotions like sadness and anger,” she says.
All traumas are not created equal. In fact, traumatic events are divided into two categories, “big T” and “little t” traumas. “Big T” traumas may include the death of a parent, sexual abuse or childhood abuse. “Little t” traumas aren’t tied to a single event; rather, they occur when we’re repeatedly exposed to painful interactions, such as bullying, peer rejection or family stress.
Research published in Psychiatric Times in 2008 states that 74 percent of women in residential eating disorder treatment programs are survivors of “big T” traumas like sexual abuse. And according to Megan Ross, an expert in eating disorders, “little t” traumas may be even more likely than "big T" experiences to contribute to the development of anorexia nervosa. Contrary to popular belief, disordered eating is rarely about food or appearance.
According to Dr. Bessel van der Kolk, a trauma expert and psychiatrist, trauma triggers deep feelings of helplessness, and the body remembers this emotion. But experiential and somatic techniques can help trauma survivors reconnect with their bodies in safe ways, allowing them to talk about the feelings and memories that plague them.
Nonverbal therapy can help
For many people with eating disorders or histories of trauma, it’s challenging to name the emotional pain that underlies their disordered behavior. Because their distress can’t be described in words, the eating disorder becomes an expression of emotional suffering that’s “acted” out by self-starvation, over-exercise, binging and purging.
Unfortunately, traditional talk therapy relies on a verbal dialogue between patient and therapist to bring about healing. If a patient can’t describe their suffering in words, recovery can be difficult.
Because of these psychological complexities, eating disorders sometimes call for a variety of therapeutic approaches. Talk therapy helps patients gain insight into the origins of their illnesses, while somatic and experiential techniques can help repair the broken mind-body connection.
“Attachment issues are traumatic because they affect one’s ability to trust and rely on others,” Latimer says. “When this trauma happens at a very early age, it can interrupt the development of the mind, body, and spirit.”
Latimer’s not aware of any psychotherapists who endorse the “bottle-feeding” intervention shown in “To the Bone,” but she says it may be considered an experiential-based technique. These approaches are rooted in theories surrounding family therapy, using actions instead of words to help foster behavioral change.
For example, the pioneering family therapist Virginia Satir developed a form of experiential therapy called “family sculpting.” This method invites family members to “act out” their individual roles by creating a “sculpture,” which provides visual images that words cannot fully describe.
Here, one person is the “sculptor,” placing family members in positions and postures that visually convey their relationship and communication patterns with each other. The image illuminates the family’s narrative, helping them identify and express buried feelings, so they can discuss, for example, how one person’s eating disorder affects other members of the family.
Other forms of experiential techniques include art therapy, dance and movement therapy, and animal therapy. These techniques are always used in conjunction with other empirically supported approaches, like cognitive behavioral therapy, providing a holistic treatment plan for the patient.
Every person with an eating disorder has a unique background that informs the narrative underpinning their condition. Incorporating various treatments, though, can allow a patient to reconnect with their mind and body.
“The goal of [an] eating disorder’s treatment is to help patients listen to their somatic cues,” Latimer says. “This is often scary, because they don’t trust their bodies. But therapy helps the patient identify new ways to feel in control, helping them let go of the illness.”