During recent years, television-based portrayals of mental health problems, particularly addiction, have exploded, both in terms of the number of shows addressing these issues and in their viewership. Leading the way is the A&E network whose prime time hit, “Intervention,” is a reality program that documents individuals and families struggling with addiction. During the show, protagonists prepare for, and execute, a Vernon Johnson style Intervention method. Influenced by the early success of this show, A&E now airs the reality programs “Obsessed,” which tracks the lives and treatment of those with anxiety disorders, and “Hoarders,” which follows individuals who obsessively accumulate possessions. “The Cleaner,” which attracted 1.1 million viewers aged 18-49 during 2008, is the first original scripted drama to appear on the network in many years. Its plot features the efforts of William Banks, who is in recovery from drug addiction, as he assists others who are dealing with addiction to attain sobriety. This week’s Addiction & the Humanities examines this show and whether it is representative of the addiction recovery process in popular culture; further, this issue assesses if the portrait of recovery presented in “The Cleaner” is accurate and helpful.
The Show
The life of the show’s executive producer, Warren Boyd, inspired the development of “The Cleaner”; this fact is displayed at the start of each episode. The show’s protagonist, Banks, is an “extreme interventionist” willing to secure the sobriety of his charges by any means necessary. As an episode which aired August 4, 2009 demonstrates, these means include restraining a nurse and prominent surgeon as they experience the withdrawal symptoms associated with sudden termination of amphetamine use. This pair arrives under the care of Mr. Banks as a result of an ultimatum by the hospital administrator who has hired Banks – get help or lose your job. Both characters are incredibly ambivalent about change, sometimes extremely resistant, and at other times eager for terminating use. By the end of the episode, the nurse, having been abducted and forcibly detoxified in a garage, chose to end her relationship with the surgeon, who is once again using amphetamines. Similar storylines have punctuated the majority of the series. This common storyline highlights Mr. Banks and his team’s attempts to engage their clients in discussions about their addictions, but ultimately they employ secretive, deceptive and coercive means to engage their clients in the detoxification process.
The Cleaner and A&E logos are owned by A&E.
Representation of Recovery
Although “The Cleaner” makes for a good television drama, it has a number of fundamental flaws that create unnecessary problems and make for a misleading representation of addiction and the recovery process. First, the language of each episode is peppered with references to “addicts,” “junkies,” and “getting clean.” Such language devalues the people referenced in this way and contributes to the stigma associated with addictions, particularly substance abuse. Even the show’s title is a subtle reinforcement of the idea that those with addiction problems are “dirty” and must “get clean” – a stigmatizing suggestion. The role of stigma in addiction treatment and recovery is complex and still under investigation; Luoma et al. reported that individuals in treatment for drug and alcohol abuse evidenced high levels of stigma (Luoma et al., 2007). They also found that the shame associated with the stigma of being a substance abuser negatively correlated with measures of quality of life and psychological functioning (Luoma et al., 2007). Perceived stigma also has been shown to be a barrier that keeps substance abusers from seeking treatment. In one study, 49.2% of drug abusers and 54.3% of alcohol abusers reported delaying treatment because of stigma (Cunningham, Sobell, Sobell, Agrawal, & Toneatto, 1993). By consistently using derogatory terms for those with addiction problems, “The Cleaner” contributes to the stigma associated with being a substance abuser. This stigma might discourage individuals from seeking treatment.
The role of William Banks as an extreme interventionist derives from the Johnson Intervention model of motivating – some might argue coercing—those struggling with addictions to enter treatment. Using this traditional intervention model, friends, family members, and others within the close social network of the individual work with a professional interventionist to encourage and motivate the individual to immediately seek treatment to remediate their addictive behaviors (Fernandez, Begley, & Marlatt, 2006). Studies of the utility of the Johnson Intervention model have produced mixed results and wide-ranging rates of treatment engagement (Logan, 1983; Miller, Meyers, & Tonigan, 1999). A number of less confrontational, social network centered intervention approaches have been developed, such as the CRAFT (Community Reinforcement and Family Training). The CRAFT relies on Motivational Interviewing and behavioral techniques employed by the social network to encourage treatment engagement by the individual with addiction problems. In a randomized control trial that directly compared treatment engagement after utilizing the Johnson Intervention or the CRAFT approach, treatment engagement for Johnson Intervention participants was 23% compared to 64% for CRAFT participants (Miller et al., 1999).
The interventions presented in “The Cleaner” deviate from both the Johnson Intervention and the CRAFT model in a number of key ways. Primarily, Banks and his team are often strangers to the clients they are attempting to help, and broad social networks are absent from the process of encouraging individuals to seek help. Furthermore, the interventions depicted are substantially more confrontational than those that current research would support. Mr. Banks and his team often strong-arm those “nominated” for their services into accepting on penalty of losing their jobs, their children, or things they are expected to value more than their addictive behavior. Evidence does not support this aggressive, provoking approach to behavior change. In fact, research indicates that such methods can be deleterious (Allen, Sprenkel, & Vitale, 1994; Miller, Benefield, & Tonigan, 1993).
The most serious flaw in “The Cleaner” is that the individuals targeted by Mr. Banks’ interventions are not the agents of their own recovery. Flying in the face of the well-established stages of change model for behavioral change, the show seems to imply that individuals can be forced and/or coerced into sobriety through means of deception, threats and even abduction. Once free of thought clouding substances, these newly detoxified people readily will choose to remain sober. Without the active engagement of those that are addicted, and a fundamental desire to modify the behaviors associated with the addiction (e.g. drug or alcohol use) sustained recovery is unlikely (Shaffer, 1992). Empirical evidence shows that, for those in substance abuse treatment, the personal motivation for behavior change is a critical component of recovery by (Laudet, Magura, Vogel, & Knight, 2003; Laudet & White, 2008). Portrayals of recovery that stem from coercion rather than active engagement by those living with addictions are not only misleading, they potentially can be damaging. A&E advertises the show as being “inspired by actual events”; this illusory representation might provide viewers with the false notion that all individuals can be forced into recovery. While coercion might work for some, it is not a solution for all. Additionally, “The Cleaner” provides no room for the possibility that those with addiction issues will abandon their addictive behaviors independently. Exclamations of “this is your only chance” and similar phrases often are declared. The show ignores the fact that many individuals can, and do, initiate their own recoveries. By consistently downplaying the role of those with addiction as primary influences in their recovery – such as being passively “cleaned up,” while strapped down to a gurney in a garage – “The Cleaner” presents an inaccurate picture of the recovery process. This image is unlikely to be helpful for the majority of those with addiction issues.
“The Cleaner” also fails to address the agonizing ambivalence of those with addiction problems (i.e., the conflict between feelings of wanting to continue to engage in addictive behaviors while simultaneously wanting to quit). This is a key component of the addiction experience that must be managed to more forward with recovery (Shaffer, 1992). While the show portrays moments of denial and ambivalence, the Cleaner does not address these matters within the current theoretical understanding of addiction recovery. Rather, ambivalence is portrayed as moments of personal weakness. While the surgeon in the aforementioned example notes that he uses amphetamines to enhance his performance at his incredibly demanding job, he also expresses the desire to terminate his drug use. Only the latter is relevant to Mr. Banks. Although acknowledging and working through this ambivalence is key to a successful recovery for the doctor, here it is largely minimized and ignored. This portrayal is yet another misrepresentation of recovery perpetuated by “The Cleaner.”
The treatment portrayed ends when the individual has completed the detoxification process with the assistance of Mr. Banks and his team. There is minimal reference made to continued recovery or relapse prevention once sobriety is achieved; recovery groups, inpatient treatment and sober living are only mentioned marginally throughout the show’s second season. Given the marginalized role of treatment and recovery beyond the initial detoxification, viewers of the show might infer that addiction recovery is as easy as a single forced episode of sobriety. In reality, addiction recovery typically is a long-term process punctuated by multiple attempts at treatment and relapses to use (Dennis, Scott, Funk, & Foss, 2005; McLellan, Lewis, O'Brien, & Kleber, 2000). For many with addiction problems, the path to recovery is long and is made possible by emotional support from social networks, learned stress and temptation reduction strategies and, above all, the motivation to change addictive behaviors (Laudet & White, 2008). The minimized portrayal of the extended recovery process by “The Cleaner” falsely represents the true experiences of many in recovery from addictions.
Conclusion
Although “The Cleaner” bills itself as based in fact, its portrayal of addiction recovery is pure fiction. Evidence suggests that social-network based and less confrontational approaches to recovery initiation have greater success rates for treatment engagement than more confrontational approaches. The process of recovery is impossible without the user’s active engagement and desire to disengage from addictive behaviors. Individuals rarely can be coerced to abandon behaviors with immense biological and psychological components. Individuals respond most effectively when they can choose to engage in the recovery process. Additionally, managing ambivalence is a critical component of the stage-change pathway that must occur before recovery can endure. The propensity of the “The Cleaner” to downplay ambivalence is detrimental to the show’s viewers who might interpret such ambivalence as unusual. It is unclear why “The Cleaner” takes such a heavy-handed and unrealistic approach to portraying the recovery process. The show is built on the premise that assisting individuals in engaging in recovery is a good and noble thing. Why, then, does the show continually refer to those with addiction problems in stigmatizing ways and portray recovery in unrealistic terms? As a work of dramatic fiction, “The Cleaner” has the potential to entertain audiences, but as an accurate portrayal of recovery, the show misses the mark. By touting itself as being based in fact, “The Cleaner” does disservice to its viewers.
Editor’s Note: After the writing of this Addiction & the Humanities article, the A&E network announced that it has cancelled “The Cleaner.” It is unclear why the network has taken this action, but perhaps audiences reacted to the errors of the show by tuning in less and less.
-Erica Marshall
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References
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Dennis, M. L., Scott, C. K., Funk, R., & Foss, M. A. (2005). The duration and correlates of addiction and treatment careers. J Subst Abuse Treat, 28 Suppl 1, S51-62.
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Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles. J Consult Clin Psychol, 61(3), 455-461.
Miller, W. R., Meyers, R. J., & Tonigan, J. S. (1999). Engaging the unmotivated in treatment for alcohol problems: a comparison of three strategies for intervention through family members. J Consult Clin Psychol, 67(5), 688-697.
Shaffer, H. J. (1992). The psychology of stage change: the transition from addiction to recovery. In J. H. Lowinson, P. Ruiz, R. B. Millman & J. G. Langrod (Eds.), Substance abuse: a comprehensive textbook (Second ed., pp. 100-105). Baltimore: Williams & Wilkins.
All recovering addicts need a support system. My boyfriend is a recent recovering addict and life is hard for him. We have watched the show “The Cleaner” and it was great. The show has real concepts and most of it my boyfriend can relate too as can other addicts.
Posted by: Lisa Lewis | Wednesday, July 14, 2010 at 02:32 PM