"Sex Rehab with Dr. Drew," is a reality television show that tracks a group of celebrities whom enter psychiatric treatment for sex addiction. Enticing, right? Unfortunately this show breaks few barriers in following the traditional reality TV recipe: one part spontaneous behavior, one part rehearsed behavior, and a dash of structure. It is an entertaining show that does many things well, and in the service of being effectively persuasive I am going to list those pros before diving into the cons.
Dr. Drew leads a treatment team that appears to consist of a therapist and a nurse. The roles are clearly constructed with Dr. Drew playing the leader (e.g. we start group because I say we start group), the nurse handling the grunt work in the trenches (e.g. setting limits as the human alarm clock) and the therapist serving as the educator and, at times, bad cop to Dr. Drew's good cop.
The Pros: The treatment team exudes a genuine desire to help others, Dr. Drew and the therapist commit to a coherent theoretical model (sex as addiction), treatment unfolds at the individual and group level (we are going to help you battle personal demons and bond as a social support through this difficult time). It should be mentioned that Dr. Drew's greatest clinical strength is the Rogerian trifecta of genuine warmth, empathy and unconditional positive self-regard. Considering his maleness and background in medicine this is a pleasant surprise. Watching Dr. Drew as he listens to a client tell his/her story is to watch rare, clinical beauty in action. He listens to every word, responds with spontaneity and vulnerability, asks only enough questions to skillfully access the client's mindset and then helps the client to guide the therapist down the appropriate path of inquiry. It takes patience, courage and generosity to do this. He is sitting with the client in such a meaningful yet subtle way that his impact is often missed by the client, let alone the viewer. In my opinion, Dr. Drew is the real deal.
Despite these positive qualities and the presumption that celebrity-based, reality television is not the best source of effective therapy, there are a few key missteps that I'd like to highlight:
Problem #1: Stuck in the past
The treatment team subscribes to the medical model of treatment. Meaning, Dr. Drew and others views the clients as "patients" with problems that are reflective of a "disease," a point symbolized by the stethoscope that Dr. Drew is always wearing but never using. The field of clinical psychology has been hoping to evolve past this superficial conceptualization toward a richer understanding of people as unique products of social, cultural and psychological forces. Unfortunately, there's not much nuance and depth in Dr. Drew's daily statement that each patient is miserable because of a relentless addiction to sexual activity that comes with all the requisite baggage - tolerance and withdrawal symptoms and stereotyped "addict" behavior. This treatment stance spins the individual less as unique sufferer and more as suspicious addict-patient. The clients, consequently, are likely to learn to perceive themselves as helpless victims of an uncontrollable addiction, the cure to which remains fully within the control of the doctors. Further, this disempowering identity only increases in saliency and shame as labels like "addict" are excessively thrown around.
Problem #2: Missing the assessment boat
By episode three a monkey wrench has been thrown into the machinery of treatment in the form of Kari-Ann. She is an omnipresent force of disruption. She ignores commitments to treatment, splits the staff, complains about everything and alienates everyone. The nurse's head is on the verge of exploding, one patient is on the verge of leaving and, of course, Kari-Ann remains untreated, trapped in her own vicious cycle of self-destruction. This monkey wrench results from weak diagnostic assessment. Yes, viewing everyone as an addict is part of the problem but the other problem is that neither Dr. Drew nor the consultant brought in to interview Kari-Ann seems to recognize that she is personality disordered. Now, since I just criticized the notion of labels, I won't turn to the DSM bullet points for more detail, but I will say that the interpersonal flare-ups, low self-esteem and aggressive defenses that seem to drip from her pores reflect a pervasive pattern born from much deeper issues than addiction, namely a sensitive temperament, a problematic attachment process and, in all likelihood, an invalidating environment. Kari-Ann is rebelling against treatment to be sure and her cry for help should be answered with a more precise diagnosis that brings clarity and validation to her suffering, not blank looks and broken-record reminders that "group is starting."
Problem #3 Residential thinking
I like the nurse. She brings high energy to a tough, thankless role as group-treatment punching bag. However, she represents a problem that I've experienced first-hand in residential settings - lack of knowledge about the theory behind structure and, for that matter, human motivation. In my mind, the real goal of structure (having group at this time, going to bed at that time) is psychological not practical. I mean what's the long-term goal? These are grown adults who like to party and in two weeks when they're back in their old routines, do we really think they're going to stick with some artifical self-imposed curfew? Of course not. Being punctual to group is less important than slowly learning that those around you are going to provide safety and predictability, which sends an implicit message of consistency and affection. The goal is an attachment replacement procedure that ushers in positive parenting and an optimistic view of social engagement. So, when the clients avoid structure it should be viewed as a test. The rationale might vary - "I'm tired, I'm angry at this group member, I'm still ashamed from yesterday's group" - but the response should always be the same: open curiosity as to the specific problem and a steady supply of love. It may be sappy, but it's true. Unfortunately, nobody has told the nurse any of this, so when she goes to rouse a group member from bed or cut off a cell phone conversation, healthy structure and validation become replaced with rigidity and power struggles. Her behavior and attitude dictate that she wants punctuality more than she wants to parent.
Possible solutions to these problems come in the form of open communication and sensitivity to group dynamics. Moving forward from "being stuck in the past" involves dropping labels and providing enough space for each individual to tell their life narrative and connect the dots between their core beliefs and their suffering. Then, instead of settling for "addict" each group member can pursue a unique, rich and healthy title to their life story. Docking the "assessment boat" requires turning an eye toward personality dynamics and learning about each group member with greater sensitivity and specificity. This puts behavior into context so that, for instance, Kari-Anne's disruptive nature can be viewed as a predictable response to psychological deficits versus such vague and inaccurate explanations as "she is help-rejecting, uncaring, and mean." Residential thinking can be reframed with open communication, to everyone, all the time. People cannot be treated as sheep to be herded, so flexible limits and boundaries need to be established and explained to the group as best-fit treatment, not as double-standards or preferential treatment. This needs to be ongoing and democratic because as episode three and four demonstrate, the group can become a fragile force that relishes conflict.
