Back in May, New York rapper Young M.A. sat down for what may have been her first psychotherapy session. “I heard you are excited as hell to be here today,” joked her therapist, Dr. Siri Sat Nam Sing. M.A. laughed in response and motioned to the glass of champagne that she sipped from throughout the session. Singh then began to probe her with questions about her fame, her sexuality, and the death of her brother; she responded openly, with honesty and vulnerability. The session could have been powerful for M.A., an introduction to the kind of regular talk therapy so many of us need but do not have access to. But at the end, she and Singh said their goodbyes as if they didn’t plan to see one another again anytime soon. And why would they? M.A. had just bared her soul for a 22-minute episode of Viceland’s The Therapist, one stop on the promo run for her debut album, Herstory. Effective therapy requires both parties’ commitment to consistent meetings over a period of time, but The Therapist is a TV show, and so the next episode would need another performer with a new set of traumas to expose and a new project needing promotion.

Ever since the rise of reality television, there have always been shows that straddle the line between entertainment and exploitation. But with its combination of medical expertise and vulnerable famous (or fame-adjacent) patients, the reality TV therapy show genre is one of the most cringeworthy. Addiction therapy, sex therapy, marriage counseling, and family therapy have all been adapted for television. And despite the ethical grey areas these shows situate themselves in, they remain popular. For many viewers, they are the only example of what therapy looks like; unfortunately, their depictions couldn’t be more misleading.

Dr. Siri Sat Nam Singh sits across from rapper Young M.A. during a 2017 "therapy session".

Without a doubt, Dr. Drew Pinsky is responsible for the advent of reality TV therapy. After years spent working as a medical professional in and out of the entertainment industry — he hosted Loveline, a call-in relationship advice radio show that has found new life as a podcast, for 30 years and acted as the “health and human relations expert” for reality show Big Brother in 2000 — Pinsky became the star of his own addiction therapy show, Celebrity Rehab with Dr. Drew, in 2008. The show, whose first season starred Daniel Baldwin, Jeff Conaway, Brigitte Nielsen, and other less bankable celebrities, was a huge hit, spawning two spin-offs and running for six seasons on VH1. But many people critical of the show voiced concerns that it was a potentially harmful enterprise.

Pinsky’s involvement with Celebrity Rehab as both a clinical therapist and an executive producer seemed obviously problematic, not to mention the fact that he was helping put his patients’ lowest moments on air for all the world to see. But the murky ethicalities weren’t what eventually caused Pinsky to end the show in 2012. Rather, it was that he was “tired of taking all the heat” each time a former cast member died. Nine years after it first aired, five people who appeared on Celebrity Rehab have died of causes related to addiction and/or mental illness.

The practice of parading vulnerable patients and licensed medical professionals in front of dubious television therapy projects continues with shows like Couples Therapy and Family Therapy, both starring and executive produced by Dr. Jenn Mann; Marriage Boot Camp: Reality Stars and Marriage Boot Camp: Reality Stars Family Edition starring Dr. Ish Major and Dr. Venus "Dr. V" Nicolino; and Viceland’s The Therapist. Other shows, like VH1’s Love & Hip Hop and, less frequently, Bravo’s Real Housewives of New York, also depict their subjects in therapy sessions. Regardless of the show or network, the sensationalism of conflict is prioritized over boring but essential things that happen in therapy, like learning coping skills.

“[In therapy,] sometimes you’re talking about fairly mundane things in ways that may not really hold that much interest for a viewer.”

Privacy and confidentiality, two foundations of psychotherapy, are the first things to go when sessions are broadcast on TV. But the act of filming sessions isn’t in itself so odd. Recording therapy for educational purposes is common in research and teaching institutions. And all a physician needs to do in order to film their patients is get informed consent. Back in 2008, Pinsky told the New York Times that he was initially skeptical that televised therapy could be ethical. However, he decided to go forward with the show because he felt there was a need for representations of therapy on television. Showing celebrities in therapy, he argued, was preferable to showing regular people in therapy because only celebrities, with their intimate knowledge of show business, would be able to give informed consent. It doesn’t hurt that seeing celebrities break down is also a big draw for viewers.

What goes on off-camera may determine what makes a show ethical or not, but there are plenty of red flags on such shows that call into question just how much the participants know about what they are getting into. Take, for example, the 2016 Viceland special YG & the Therapist that inspired the currently airing The Therapist. The special, which documented two therapy sessions between Singh and rapper YG and ultimately profits off of broadcasting the traumas he discussed, takes many cringe-inducing turns, the biggest being when YG shows up for his second session heavily inebriated. After confirming that YG is indeed drunk, Singh decides to go ahead with the filmed session anyway. According to Dr. Lynn Bufka, associate executive director for practice research and policy at the American Psychological Association, there is no hard and fast rule on whether or not a therapist can or should continue a session with a patient who is inebriated. But from a layperson’s perspective in watching the show, knowing YG was drunk and only meeting Singh for the second time, whether or not he could have reasonably consented to be filmed during that session seems to occupy a grey area.

There isn’t research detailing precisely how reality TV therapy shows affect viewers’ perceptions or considerations of trying therapy. And while, as Bufka told The Outline, depictions of quality therapy can serve to demystify the process for those who are unfamiliar, entertainment and quality therapy don’t always come hand in hand. “Psychotherapy is often not that interesting to people other than those who are engaged in it,” said Bufka. “Sometimes there’s a lot of universal topics that that come up that transcend the individual psychotherapy that's going on but sometimes it’s really specific to the person sitting in the room and sometimes you’re talking about fairly mundane things in ways that may not really hold that much interest for a viewer. But it's the necessary part of psychotherapy.”

As Bufka explained, the onus is ultimately on the medical professional to determine what’s in the best interest of their patient. “The first thing that we always think about in these kinds of situations is will it be a benefit to the individual receiving care,” Bufka said. “I don’t want to ask them to do something or engage in something where they feel like they have no choice but to say yes because I'm their doctor. And so you’re very very very careful about talking with individuals about that kind of situation.” Ethically, these considerations must be taken into account whether or not the professional doing the considering is looking to be the star of a hit TV show.

It’s in part the responsibility of state medical licensing boards to keep doctors in line; they rely mostly on public complaints to find out when doctors are doing something wrong. For example, in California, where Pinsky, Mann, and Singh are licensed, 65 percent of the complaints that the state medical board received about physicians and surgeons in the ’15-’16 fiscal year came from the public, most concerning gross negligence and incompetence. Thanks to those and other complaints, the board took 388 disciplinary actions against offending professionals. But without the careful observations of everyday people, enforcement of medical standards and ethics would be a much harder endeavor to take control of.

Dr. Jenn Mann and 16 and Pregnant stars Catelynn Lowell and Tyler Baltierra during VH1's Couples Therapy With Dr. Jenn Reunion in 2014.

Luckily, large numbers of people are watching these shows. Unluckily, many of them may not have a good idea of what therapy is supposed to look like in the first place. The National Alliance on Mental Illness reports that one in five adults experience mental illness, but 60 percent of those affected do not get treatment, with African, Hispanic, and Asian Americans receiving treatment at significantly lower rates than white people.

In the end, when something is on national television, the assumption is that if anything were wrong, the show wouldn’t air. Having a licensed medical professional or two on a show only bolsters the image that there are professionals working behind the scenes to make sure no harm will come to anyone involved in filming. No matter how distressed the stars of these shows may appear, audiences wanting to enjoy such shows have to either trust that the patients they are watching are going to be ok or, more sinisterly, not care. And unless awful things happen to them, as they did to at least five people from Celebrity Rehab, reality TV therapy shows will continue to be a feature of American television.