A New Reality for Psychiatry: Is Reality TV a Friend or Foe?

Irving Schneider, MD, aptly said: “If psychiatry had not existed, the movies would have had to invent it.”¹ The same can be said regarding reality television (TV), which is consumed regularly by almost 40% of American adults.² Historically, Hollywood has both increased awareness of psychiatric disorders and perpetuated stigma and misconceptions. Similarly, portrayals of mental illness and of mental health professionals in reality TV have one foot in the fictional psychiatry world and one foot in the real world.

Evolution of Psychiatry in Reality TV

Mental health primarily existed backstage in early reality TV, which was mostly competition-based shows. For example, there were consultant psychologists for Survivor, and an internal and addiction medicine physician on Big Brother.^3,4 Their roles included screening contestants and providing support. M. Gene Ondrusek, PhD, a psychologist consultant for Survivor, described assessing for medical and mental health disorders, as well as interpersonal interaction patterns and behavioral responses.⁴

By the mid-2000s, therapy often appeared as a plot device, such as in Breaking Bonaduce, where couples therapy was used to point out cheating and flaws.⁵ These presented real risks of negative impressions of both mental health disorders and therapy.

More recent reality TV models a more documentary-like style, following the daily lives of reality TV stars, including their therapy sessions. These series allow the audience to join treatment sessions, breaking the fourth wall (the theoretical space that separates performer from audience). For example, in The Real Housewives of New York City and Bethenny Ever After, viewers witness therapy sessions between Bethenny Frankel and Xavier Amador, PhD, addressing issues of friendship, divorce, career, and childhood trauma.⁶ Couples therapy in Bling Empire allowed for the exploration of family trauma and abandonment issues.⁷ It is important to note that the information viewers have about any person or treatment on TV is solely that curated by participants. As such, when at all possible, we strive to give the benefit of the doubt to treaters and their chosen methods, assuming that even if we disagree with an intervention or a method, there may be information we do not know of that perhaps would impact our impressions. Allowing a camera into the therapy room to record it for entertainment value in millions of homes appears problematic. Recommendations of what would be helpful include clear consent from the patient, planning in advance what the patient is open to discussing on air (including the risks and benefits), and responding to disclosures that the patient wishes to make on screen. A psychiatrist appearing on reality TV needs to be circumspect in the way they make statements, as this is different from usual therapy. Where possible, reality TV psychiatrists could highlight or teach therapeutic skills, which would be helpful not only to the patient but potentially to the audience too. The reality TV psychiatrist should aim for nonthreatening exposure to audience members, rather than trying to be too memorable as a specific character. The psychiatrist would also want to ensure that the production company provided resources for specific mental health areas discussed and suicidality.

Representing Illness and Treatment

There are no clear guidelines regarding how to responsibly represent psychiatric treatment and illness on TV. Even scripted TV may miss the mark on information accuracy at times.

Reality TV faces additional challenges compared to scripted TV, including the involvement of real people with real illnesses and the likely complex process of determining which information about those people and illnesses will be publicly shared. Some reality TV shows explicitly feature psychiatric illness or mental health treatment, such as Couples Therapy, Hoarders, Intervention, My Strange Addiction, LA Shrinks, and Supernanny. Mental health professionals are on the scene, such as David Tolin, PhD, on Hoarders.

Many reality stars self-disclose either their own diagnoses or the diagnoses of family and friends (Table) and often offer their own thoughts about psychiatric diagnoses. Regardless of their accuracy, these diagnoses are discussed in this arena and the implications of these discussions on TV warrant consideration by the psychiatric field. At the very least, patients consume these shows, and, as such, the information on reality TV about mental health likely influences their perceptions of mental health conditions and treatment. Reality TV seems here to stay, and professional organizations may want to discuss Goldwater-type guidelines in more detail. Solving complex mental health issues in time for a commercial break can set up false expectations in viewers too.

When interviewed, reality stars have reported the potential for decreased stigma from portrayals of therapy. Jamie Otis (Married at First Sight) said, “10, 20 years ago, therapy had such a stigma to it. That means you’re flawed. Now people are able to come out a bit more and share their stories.”⁵ Similarly, Lindsay Hubbard (Summer House) said, “My TV show is helping normalize therapy.”⁵

Therapists also report the positives of portraying therapy on reality TV. Esther Boykin, LMFT, therapist on The Real Housewives of Potomac, similarly explained, “People who are watching these shows, who can relate to the storylines, who relate to having difficulties as an adult, having difficulties with their mother, or who have struggles with their husband or have trouble conceiving, understand that watching people has value; it helps people to feel less alone.”⁵

Yet cameras in the therapy room of reality TV shows and producers determining what makes the cut⁸ can most certainly change what is said and the course of therapy.

Psychopharmacology also plays a role in reality TV, with stars discussing their use of medications, such as antidepressants. In 2023, The Real Housewives of Miami showed one of Adriana de Moura’s ketamine treatment sessions, where, on camera, she reported conversing with her deceased father and brother.⁹ The encounter appears to viewers to have been beneficial for de Moura, helping her let go of lingering emotional pain. However, showing one instance, albeit positive, of a psychiatric treatment is hardly providing the public with informed, balanced information about a treatment modality—particularly one that is a controlled substance with its attendant risks. And yet, we know that those in the public eye are tremendously influential on individual decision-making. Although reality TV does not (and should not) purport to give medical advice, it may affect public perception of medical topics, and its impact on public perceptions of health conditions and treatments should be understood.

The dark side is whether these short clips of sessions are really therapeutic for the patient, or whether they are creating conflict and entertainment. Privacy and confidentiality become lost when therapy is entertainment. The UCAN Foundation, an organization dedicated to improving reality TV’s treatment of mental health issues, cofounded by former Love is Blind cast member Nick Thompson, has raised concerns about harm done to cast members and the need for guidelines to enforce the privacy of evaluations and protect emotionally distressed cast members. It appears, from their website as of March 2026, that their advisory board includes one psychologist, although no psychiatrists.¹⁰

Psychiatric Impacts Behind and In Front of the Camera

Research is starting to consider reality TV’s effects on viewers’ mental health, including regarding personal aggression, body image, illicit substance use, and narcissism. Concerns have been raised about verbal and relational aggression in many reality TV programs and the potential to increase aggression among viewers.¹¹ Young adults report negative impacts on their own body images related to reality TV, and they may experience depression, anxiety, and suicidal thoughts related to poor body image.¹² For those with eating disorders, negative effects may occur more often. Data from a recent European study showed that after watching an episode of Germany’s Next Topmodel, women who self-reported having eating disorders had a stronger increase in body dissatisfaction and negative effects than women without eating disorders.¹³

Reality TV shows sometimes involve discussion of illegal substance use and the misuse of prescription drugs. In a study of college students, researchers found that watching reality TV and identifying with reality TV characters were each associated with an increased risk of illegal drug use.¹⁴

Finally, researchers tested the hypothesis that viewers watching narcissistic reality TV characters could themselves have increased narcissism, with their results suggesting that viewing can help shape narcissism levels.¹⁵

Analyzing and identifying trends among those who participate in or consume reality TV is a Herculean task. Both groups are likely quite heterogeneous, with individuals who use this form of media for a wide variety of reasons and to varying degrees of intensity. However, suicide, a public health issue that is unfortunately too prevalent, has been raised as an issue for reality TV stars. 

At least 28 reality TV stars have died from suicide.¹⁶ Multiple stars of the British romantic competition–based show Love Island have died by suicide, including a former host and 2 contestants,¹⁷ prompting the UK Parliament to evaluate potential ethical concerns about the treatment of reality TV stars.¹⁸ Concerns noted included whether the shows had a duty to the participants, such as an obligation to provide psychological support and to avoid excessively psychologically taxing situations.

As of 2025, Love Island USA has a mental health support team that includes 2 on-call psychologists and requires contestants to receive psychological assessments before beginning the show.¹⁹

Discussing Reality TV With Patients

As with all forms of entertainment and artistic media, there are opportunities to foster meaningful conversation and address bias, but also possibilities to reinforce stigma. Inquiry about patients’ media consumption, including duration, type, and content themes, can lead to fruitful dialogue. More specifically, asking about how the media portrays mental illness and its treatment can result in open discussions about the patient’s own perceptions about their illness and treatment, their responses to treatment, and sociocultural understandings of psychiatry and mental health care.

TV media and the reality TV genre have led to real-life portrayals of mental health treatment, including the fact that therapy is longitudinal. A representative from the American Foundation for Suicide Prevention said this about reality TV: “They show what [therapy] looks like and that it’s not a quick fix; that therapy is generally a positive experience.”⁵ However, discussions with patients can focus on the intent behind reality TV, namely entertainment, including the crafting of a storyline based on a cast member’s life experience, in a short scene or series of scenes. This focus will necessarily simplify the scope of a person’s engagement with mental health treatment and may result in assumptions about mental health providers, treatment modalities, and treatment outcomes.

We recommend that clinicians explore these dualities (unmasking or normalization of mental health treatment vs simplification of the process to fit into episodes or storylines) with their patients to develop therapeutic rapport and understanding, and, importantly, to realign their patients’ experiences with treatment goals and realistic long-term outcomes.

Discussions with patients can include the fact that although identification of mental health diagnoses for reality TV stars may foster discussion and exploration in audience members, descriptions of diagnoses may be lacking in detail, misidentified, or overly simplified. Additionally, reality stars may pursue in-vogue or expensive treatments with limited evidence supporting their use, or they may have previously pursued a gold standard treatment with only partial response. These representations in reality TV may create a sense, whether true or false, of increased legitimacy or the necessity of treatment, compared with fictional portrayals.

Regardless of the direction of the dialogue, it is important for the real-world psychiatrist to maintain a neutral, curious approach to a patient’s engagement with and perception of media depictions of mental illness and treatment, including reality TV. Additionally, psychiatrists may benefit from familiarizing themselves with different popular reality TV shows, particularly those with portrayals of mental health, to further discussions with their own patients regarding impressions of their own mental health treatment and developing realistic treatment goals together.

Dr Hatters Friedman is the Phillip J. Resnick Professor of Forensic Psychiatry; professor of psychiatry, reproductive biology, and pediatrics; and adjunct professor of law at Case Western Reserve University in Cleveland, Ohio. She served as editor of the Group for the Advancement of Psychiatry volume Family Murder: Pathologies of Love and Hate, which won the Manfred S. Guttmacher Award.

Dr Ross is a forensic and reproductive psychiatrist at Trinity Health Michigan and an adjunct clinical assistant professor in the Department of Psychiatry at the University of Michigan in Ann Arbor.

Dr Kruse is a forensic child and adolescent psychiatrist and a clinical assistant professor in the Department of Psychiatry at the University of Michigan in Ann Arbor.

References

1. Schneider I. Introduction. In: Gabbard GO, Gabbard K. Psychiatry and the Cinema. American Psychiatric Press, Inc; 1999.

2. Becker K. Reality Tv viewership statistics. Gitnux. February 13, 2026. Accessed February 13, 2026. https://gitnux.org/reality-tv-viewership-statistics/

3. Melman L. Getting to know physician and Hollywood radio-tv personality Dr Drew Pinsky. Jerusalem Post. September 28, 2025. Accessed February 3, 2026. https://www.jpost.com/diaspora/article-868550

4. Survivor psychologist. CBS News. January 31, 2002. Accessed February 3, 2026. https://www.cbsnews.com/news/survivor-psychologist/

5. Burton S, Holmes L. Reality TV has been quietly normalizing therapy. Huffpost. September 11, 2019. Accessed February 3, 2026. https://www.huffpost.com/entry/reality-tv-normalizing-therapy_l_5d77d4e5e4b075210233f4f9

6. Ries Wexler J. Are the therapy sessions on reality TV shows even remotely legit? Self. August 7, 2024. Accessed February 3, 2026. https://www.self.com/story/reality-tv-therapists

7. Nath I. The power (and risks) of therapy on reality TV. Refinery29. April 14, 2023. Accessed February 3, 2026. https://www.refinery29.com/en-us/2023/04/11355793/therapists-on-reality-tv-shows-ethics

8. Prinzivalli L. How real is reality-TV therapy? Atlantic. September 20, 2016. Accessed February 3, 2026. https://www.theatlantic.com/health/archive/2016/09/reality-tv-therapy/500801/

9. Moylan B. The Real Housewives of Miami recap: specialist K. Vulture. November 29, 2023. Accessed February 3, 2026. https://www.vulture.com/article/the-real-housewives-of-miami-recap-season-6-episode-5.html

10. UCAN Foundation. Accessed February 3, 2026. https://theucanfoundation.org/ 

11. Gibson B, Thompson J, Hou B, Bushman B. Just “harmless entertainment”? effects of surveillance reality TV on physical aggression. Psychol Pop Media Cult. 2014;5(1):66-73.

12. Mental Health Foundation criticises new series of Love Island. Mental Health Foundation. June 3, 2019. Accessed March 11, 2026. https://www.mentalhealth.org.uk/about-us/news/mental-health-foundation-criticises-new-series-love-island

13. Holtmann FJ, Lalk C, Rubel J, Vocks S. Assessing the impact of a reality TV fashion model contest on women’s state body dissatisfaction, affect, and self-esteem: an experience sampling study of women with and without eating disorders. Eur Eat Disord Rev. 2025;33(4):815-824.

14. Fogel J, Shlivko A. Reality television programs are associated with illegal drug use and prescription drug misuse among college students. Subst Use Misuse. 2016;51(1):62-72.

15. Gibson B, Hawkins I, Redker C, Bushman BJ. Narcissism on the Jersey Shore: exposure to narcissistic reality TV characters can increase narcissism levels in viewers. Psychol Pop Media Cult. 2018;7(4):399-412.

16. Longman M. When reality TV contestants die, who should wepdated blame? Refinery29. Updated July 27, 2020. Accessed February 3, 2026. https://www.refinery29.com/en-us/2020/07/9826219/reality-tv-contestants-suicide-mental-health-problem

17. Peele A. How Love Island became a TV reality of sex, fame, and sometimes tragedy. Vanity Fair. June 2, 2022. Accessed February 3, 2026. https://www.vanityfair.com/style/2022/06/how-love-island-became-a-tv-reality-of-sex-fame-and-sometimes-tragedy

18. Committee announces inquiry into reality TV. UK Parliament. May 15, 2019. Accessed February 3, 2026. https://committees.parliament.uk/committee/378/digital-culture-media-and-sport-committee/news/103566/reality-tv-inquiry-launch-17-19/

19. Noble A. Can I pull you for a chat? a look into Love Island USA’s mental health team. Vogue. July 12, 2025. Accessed February 3, 2026. https://www.vogue.com/article/love-island-usa-psychologist