Celebrity Rehab and the One-Size-Fits-All Approach

March 28, 2012

What we often see in media portrayals of addiction treatment is a one-size-fits-all approach: people struggling with substance abuse all have the same “disease,” and all need to follow the same (typically 12-step) path in order to recover from it. Although 12-step “disease” concepts can be a terrific path for many people, research over the last 30 years has repeatedly found that different people need different paths. There are a variety of ways to effectively overcome addictive behaviors (under the heading of “Evidence-Based Treatments,” or EBTs), and confining someone to only one option – especially one they’re resistant to – is most likely to block them from making positive change.

In this two-minute clip from season two of Celebrity Rehab with Dr. Drew, we see the one-size-fits-all approach in action (Dr. Drew insisting that his patient Chyna accept the label of “addict” as a first step to change, when she’s expressed concern about it), as well as the negative impact this approach has on her receptivity to treatment (Chyna clearly zoning out and “yessing” Dr. Drew).

The danger in this type of interaction is one we see all the time: the powerful and (in this case) charismatic doctor/clinician/“expert” conveying in no uncertain terms to the client that compliance with his version of reality, his version of “how to save your life” is “the only way.” Unfortunately, while it is easy to get compliance (e.g. “Yes, doc, I really see what you mean, and I’m sick and tired of being sick and tired”), actually helping people internalize a real desire to do the hard work of changing is another matter. The difference? The “compliant” client walks out of rehab and returns to old patterns, happy to be free of a world they agreed with only so long as the rehab stay lasted; the client truly grappling with a path that works for them begins to confront the complexities of real life and make the continuous incremental changes needed to move forward under their own power. This client makes changes because they have come to embrace them, not been force-fed them.

Unlike the treatment depicted in this clip, evidence-based treatment would involve a broader list of options; if Chyna were unwilling to accept the label of “addict” but interested in changing her use habits, her therapist would discuss other paths toward recovery. Additionally, research suggests that one of the strongest predictors for a patient’s success in addiction treatment is feeling understood as an individual and worked with collaboratively, not dictated to. While this may seem like common sense in almost any other setting, in addiction treatment, clients who desire collaboration and understanding are accused of suffering from “terminal uniqueness,” and all their resistance to a doctor’s prescription labeled as “denial.” Evidence-based approaches would focus on Chyna’s experiences and concerns, rather than suggesting that her experiences are identical to all others (e.g. “I’m sure Shelly had those kinds of behaviors, and now she doesn’t”); or that her concerns are irrelevant and unwelcome (e.g. “It’s really not about what you believe or don’t believe”).

This is not to suggest that a patient’s impression of their situation is always the correct one, or that a therapist never has to present an alternative perspective; often the patient needs a therapist to help them see their own choices more clearly. It is true, however, and repeatedly borne out by the evidence, that the patient’s perspective must be heard, acknowledged, and worked with; not dismissed out of hand. A traditional disease-model approach too often assumes that the most important part of treatment is knocking the sense into a bull-headed patient in denial. The fallout is often a patient who’s compliant, but shut down. Too often we then blame that patient for a relapse after treatment, rather than examine the therapeutic strategy that cornered that patient and increased their resistance in the first place.

So how does an evidence-based approach handle this same dialogue? How might a therapist acknowledge Chyna’s experience of her own behavior without encouraging her to abandon the changes she’s come to treatment to make?

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