#therapy meta

[comingatthecottage]

since several people asked

So obviously I was joking when I said I would Fix Ilya and the actual progress of therapy would be long and slow and ultimately he'd be leading the way but here are some things I would keep in mind as aspects of the plan or percolating in my head while we worked. long and discussion of suicidal ideation so it's behind a cut

-co-creating a non-stigmatizing, anti-carceral plan for how to manage suicidal ideation. this could be as simple as regularly asking “hey, any suicidal thoughts lately?”, asking what kinds of lethal means he has access to, and checking in to see what his experiences with those thoughts have been lately. I’d also establish, again day one or the first day he’s feeling pretty stable, a plan for what to do when/if those thoughts become active. Would he like help reaching out to a higher level of care? A loved one? Does he consent in advance to hospitalization if there’s a crisis where his judgment is impaired? (I don’t believe in or practice involuntary hospitalization and would also explain this, no I don’t care that it’s the law, forced hospitalization makes people worse and makes it dramatically harder for them to access actual support, don’t call my licensing board on me pls)

-a focus on strengths and resources and how to shore those up. Important in general, deserved by all human beings, necessary for depressed patients. Ilya has been through a lot. He also has a lot going for him, internally and externally. He is intelligent, especially emotionally. He is incredibly empathetic and loyal. He is the best (okay tied for first) in the whole world at something he loves to do—by definition he is hardworking and dedicated. He is a good leader and a good friend to his teammates. In terms of resources: yes, he’s short on interpersonal supports, but a partner who loves him, even a long distance partner, is a big support. He had friends in Boston he could perhaps stay connected to, and a relationship with Svetlana that he could learn to lean on. He has effectively unlimited financial resources. He’s in good physical health. These all point towards a positive outlook! like literally just making a list of these things might help.

-referral to medical. neuro workup to make sure there isn’t a physiological brain issue, since depression is a common symptom of all kinds of neurological illness and he works at the Get Hit On The Head Factory. Discussion with a good psychiatrist who I collaborate closely with. i would assume that SSRIs/SNRIs would be trialed and fail (because I don’t think he would want to be on a medication with sexual side effects, and also it’s a bad fit for this kind of depression usually, i will spare y'all my SRI haterade soapbox), it’s possible that something like Wellbutrin or Lamotrigine would be helpful or it’s possible medication wouldn’t be part of the plan.

-making a diagnosis (probably major depressive disorder, recurring, moderate). Explaining, in detail, what that diagnosis means, what the prognosis is, and what it means to have a diagnosis. i’d also want to know a lot about what that means to him especially in re his mother

-a lot of listening to him share about daily life stressors. He’d probably have a lot to say bc he’s an outgoing guy and he’s lonely. initially not much of it would have a lot of emotional content, which is fine. this is also where hopefully he starts to feel comfortable talking. I would also continue to focus on strengths—what are the good things, what is he enjoying, etc. i'd ask a lot of questions about shane because he'd need a space to talk about this person in his life that's so important that he has to keep secret. not to tell him what to do in the relationship or anything. just to give him space to talk.

-then some gentle prodding to encourage him to share his feelings about these things. identifying what those feelings are like. Discussing how he’s coping with them and if there’s other methods he can think of trying. And then, crucially, starting to engage with where those feelings come from,. And listen, it doesn’t take the world’s most gifted analyst to draw the line from “I am not good enough for my boyfriend” to “I was never good enough for my father, which I know because he told me that repeatedly, usually while hitting me,” or from “Shane doesn’t really want me around” to “my mother didn’t care enough about me to stay alive.” And now we’re in it!!

-you probably don’t come right out and say those things, but you start to encourage him to draw those connections, to see where those ideas about himself may have come from, and to recognize what he learned about relationships when he was young. Two crucial things I’d keep an eye on here. First, very very important to avoid implying that “you learned about relationships from your parents” = “you are like your father (or like your mother, but especially not like your father)”. Secondly, again, strengths focused. I would be genuinely impressed with anyone who came from such a traumatic background who had developed such loving relationships and strong interpersonal values in adulthood, and I would say as much.

-the idea is that, gradually, he starts to understand that the way he sees the world and himself was shaped by his early life experiences, and that he doesn't necessarily believe those things anymore. it helps that he has always been able to keep a fair amount of psychological distance between himself and his father's ideas about him. the mom stuff would take a lot longer, like, years before he'd be willing to look right at the fact that she also taught him things about himself that hurt. but it'd be a little at a time idk i hope this answered the question and/or was interesting! tagging ppl who asked: @ober-affen-geil @dontworryfolkswetookallherteeth @assorted-fandom-things @girl-son @goldenbunniesxo @thedragonflylover

[comingatthecottage]

on the topic of bad therapy in tlg — it also makes me angry that galina drives a lot of ilya’s resentment towards shane by just. making a lot of assumptions about shane’s life for no reason? like genuinely in what world would a therapist look at a closeted asian hockey player (while knowing that ilya himself is currently being dishonest about his own mental health) and automatically assume ‘he seems to be doing well for himself ☺️’ with zero hesitation like HELLO

OK LITERALLY i know i just answered a similar ask but i can and must say more about this.

therapists should try to avoid making assumptions. therapists should entirely avoid making assumptions about third parties they have never met. it's not galina's business if shane is doing well for himself, and she has absolutely no information that would tell her if that's true or not. she knows that she perceives that ilya perceives that he's doing well. she should ask a question about one of those perceptions if that's what she wants to know

honestly it's inadvertently a perfect depiction of the harm that therapists do when we forget our job is to be with the person who is actually in the room, not to solve their relational problems or understand the other people in their lives (aka the gossip motivator, to which i am not immune). shane is ilya's biggest support system (and by far the most powerful protective factor against him harming himself). their relationship is strained in part by a misunderstanding created by differences in personalities, identities, social locations, and histories: ilya fears shane is fine and happy with his perfect hockey life and his perfect happy family and is treating ilya as a part-time amusement while shane is Everything to Ilya; meanwhile shane is in the torment nexus of "if i ever come out i will lose everything i and my parents worked so hard for, i have always had to be keenly conscious of what an outsider i am because of my race and my undiagnosed autism, luckily at least i have ilya who i love so much and always miss when we can't be together".

instead of helping ilya identify his own perspective, galina offers hers--one that is essentially a more extreme version of the misunderstanding of shane that ilya is operating under. she hears ilya's fear that shane is doing just fine without him :) and instead of naming that fear she, possibly trying to validate his perspective, tells him that the thing he's most scared of is true

which does literally create a rupture between him and the one person he needs to be able to count on! which is terrible for both of them!

[comingatthecottage]

MORE therapy meta! Have you seen the interpretation floating around tumblr that Ilya might actually have bipolar instead of unipolar depression? What do you think? In the AU where Ilya gets therapist Anya comingatthecottage instead of Galina, is that something you're wondering about before you start looking at a treatment plan?

hello! i have seen this interpretation and i disagree with it. i would definitely ask some questions tho because bipolar (especially in people who are "high functioning" yuck i hate that label) is often missed/misdiagnosed and, particularly if medication is part of treatment, that can make things a loooot worse, and i always want to help people rule it out! i'd been in therapy for over a decade before i was diagnosed as bipolar (and it took multiple years after i had an ssri-induced manci episode too! should've been a giveaway when i took zoloft and immediately almost burned my house down) so here at anya comingatthecottage therapy inc we definitely ask some questions about it

however i don't see my experiences with bipolar really resonate in ilya's character. as far as i can remember the books, and at least in s1 of the show he doesn't have any periods of sleeping little and doing a lot without feeling tired, which is my personal hallmark of "oh i'm hypomanic" (like this is literally how my psychiatrist helped me rule out whether i had a heated-rivalry-induced hypomanic episode when i realized i was writing like 2k words a day--yes, increase in goal-directed activity, but it was making me sleepy af). he's confident but i think that's his personality--he never seems grandiose in his self-assessment, externally or internally. his speech and internal monologue are pretty well-organized, his thoughts don't seem to be racing or tangential? as far as the internal experiences of mania/hypomania, i don't see it

i think some people have this headcanon because ilya does a lot of stuff that's reckless--fast cars, lots of casual sex, drug use, etc. i would say that it doesn't seem to be episodic or impulsive in the way that it is during a manic episode? i'm not expert on this part because i don't tend to have a ton of risky behaviors when manic, mostly i just start a bunch of art projects i abandon, talk really fast, don't sleep, and can't concentrate. but ilya doesn't seem to have discrete periods of time where he seeks out risks or thrills, he seems to always enjoy those things (until he settles down into a more domestic routine with shane), and they don't seem to be driven by a lack of ability to understand the consequences or a sense of invulnerability, but more by the kind of lack of care for himself that is a result of depression and trauma. he's also shown to enjoy thrills in a non-impulsive way: like fucking shane is risky, and he spends years planning for that one

tl;dr: ilya has a lot of traits (confident, impulsive, reckless, outgoing, risk-taking) that are associated with mania, but imo those are traits of his personality that are consistent over time, not symptoms that emerge during discrete, time-limited episodes of mania. not hating on anyone's headcanon, just my own opinion as one bipolar person

[comingatthecottage]

Hi I hope you don’t mind me asking bc it’s not HR related but I read your post about Galina and I’m actually really interested in what you meant by not agreeing with the medical ideas of mental health because I haven’t heard anything like that before and am super curious

So the medical model of mental health is the idea that psychological symptoms results from an underlying disease, analogous to physical diseases that affect the body. They thus would have a concrete (often assumed to be physiological, which the DSM-VI is apparently moving towards, im gonna go scream) cause, defined symptoms, and can be treated with medication or some other testable thing.

There are some good intentions behind the medical model. First of all, it lets people get insurance reimbursement for psychotherapy and psychotropic drugs. I can’t tell blue cross blue shield that my patient is sad and lonely and needs a caring person to talk to, but I can say they have an illness called major depressive disorder, and then blue cross blue shield reimburses them 75% of my fee so they can afford to keep coming back and getting therapy. the medical model is also better than what it replaced, which was generally the idea that mental health symptoms mean you are broken, deficient, evil, possessed by a ghost, etc (depending on what era we’re looking at). It takes a lot of the blame off of the patient, which is good

The problem with the medical model is that it.. is a bad model. in the sense that it is a model that poorly explains the data. for most mental health conditions, there’s no defined test for them. There’s no physical finding to prove or disprove their presence. Symptoms vary enormously from person to person. Treatment has to be individualized. i think the medical model can be useful for some things (i.e. I am bipolar, which I believe is an organic brain illness) and harmful for others (i.e. I am autistic, which is just how I am; i have intense interpersonal anxiety which is a result of the autism and my life history). the medical model also removes the role of society in creating these problems. using Ilya’s depression as an example: ilya may have inherited some risk of depression from his mother. He’s also socially isolated, a refugee from his home country, has suffered repeated traumas, and is under enormous career and minority stress. The medical model locates the problem within he patient, while other models include the role of society and others in creating them.

Also, and this research is mostly being done in addictions science but I’ll be very interested to see how it transfers to mood disorders etc, there’s some evidence emerging that the medical model actually decreases rates of symptom remission—people have higher quality of life because they don’t feel as much shame over having a “disease” as they do about having an “addiction” (both in quotes to indicate their word choices for the same constellation of behaviors, not as scare quotes), but they’re also less likely to get better because they believe the illness is out of their control.

The medical model heavily favors certain types of treatments: those that can be tested in basically a lab sciences setting, so manualized therapy treatments like DBT and medications. The effectiveness of these treatments in a real world setting in terms of actually improving people’s lives is… mixed.

I was trained in what’s called the biopsychosocial model as a clinical social worker, and I use a psychoanalytic model now. If you’re curious about these things I can say more later, for now I’m gonna try and do some fic writing!

[comingatthecottage]

i saw your essay abt galina (great stuff btw) and i’m curious what kind of therapies are out there and what their strengths/weaknesses are. i’ve read thru all the psychology today pages and stuff, but i guess i don’t really see how a lot of them are different? and what do you personally think would benefit ilya in specific?

i cannot explain every therapy modality, there are like ten thousand of them, but there are two pieces of information that are probably helpful to have: 1) what the three waves of therapy are 2) you are right, they're not that different so there have been (in the western psychotherapy tradition) three "waves" of theories about how to do therapy. i will avoid discoursing on the historical circumstances that led to each of these, but they're reactions to each other and to the times in which they involved. the "first wave" is psychoanalysis. psychoanalysis is, essentially, the idea that unconscious and subconscious drives--things that are true about ourselves that we don't know--impact our actions. this probably seems obvious today but it didn't really exist as a concept previous to psychoanalysis. psychoanalysis claims to work via free association--patient comes in, patient talks, patient eventually reveals aspects of their subconscious, analyst interprets, patient feels better (okay this is so so oversimplified). there are many many many branches of psychoanalysis because basically every psychoanalyst was a disciple of another psychoanalyst and then they had a huge falling out and decided to go create their own form of psychoanalysis. major splits include classical/Freudian, object relations, humanistic, and relational, i won't define them all. most people working from these theories today call themselves "psychodynamic".

the "second wave" is created by the most significant of these fallings out. in cognitive and behavioral therapies, the idea that understanding themselves, their minds, and their subconscious would improve symptoms was abandoned. instead, the focus was on identifying so-called distorted thinking patterns and maladaptive behaviors and modifying them through behavioral interventions. thus cognitive behavioral therapy and its many offspring: ACT, DBT, ERP, etc. these treatments tend to be time-limited, target specific behaviors, and work from specific manuals

the "third wave" is happening now. it includes body-based therapies (somatic experiencing, EMDR) and things like internal family systems therapy. these are supposed to be "bottom up approaches," acknowledging the role of the body in mental health and incorporating different parts of the self, but without going into the depth of the subconscious. in practice, these things are rarely as different as they claim to be. the mechanism of action of all therapies is the therapeutic relationship, this is pretty well established. the best therapy is one where you build a good therapeutic relationship. most therapists work at least somewhat integratively and adapt their methods to particular patients. also uh a lot of it is just repackaging of existing concepts (see uh IFS is just Jung without the shadow self), often for self-serving reasons: because theorists wanted to make a name for themselves, or because they wanted to differentiate themselves from a mentor they'd fallen out with, or, unfortuantely and recently, because they want to get rich and famous selling other therapists $15,000 training courses so they have to trademark something. the core idea is still "you talk and you feel better, or at least understand something you didn't before, or at least someone listens"

i think ilya should see a relational analyst/psychodynamic therapist, because all i got's a hammer so everything looks like a nail to me. in all seriousness: the root of his problem is deep, repeated relational trauma that took place early in his life. if he targeted cognitive distortions, he'd see some short term improvement and then develop a different set of symptoms. his PTSD doesn't seem to manifest particularly somatically. but what he does have is early-life trauma that has to do with his interpersonal relationships and into which he has very poor insight, despite being an emotionally intelligent person. basically, if the problem is your parents, psychodynamics is the solution. more on this in my next essay apparently

[comingatthecottage]

just read your posts on how galina as a bad therapist and how therapy is poorly represented in tlg and THANK you for laying out everything that was wrong! i hear relatively little criticism of the therapy in the book and she’s such a bad therapist it was grinding my gears the whole time. another thing i thought was super super strange that you kind of touch on is obviously she admits to knowing who ilya is but following that she continually brings up things that have happened to him that she learned from like outside hockey news instead of letting him say it first?? which was so so wild to me like you mentioned she kind of makes ilya talk about irina’s suicide but if i recall im pretty sure she’s also brought it up by going oh yeah i know from your foundation announcement that your mom killed herself. and she does that a few more times where in my opinion she breaches the boundaries of their relationship by essentially telling ilya events of his own life that she got from outside sources?? i’m no therapist so correct me if i’m wrong but that seems like a super inappropriate thing to do - famous client or not.

i've never dealt with this but if i did i actually would just plan to be super upfront with the patient about what i know about their work? first of all bc i cannot tell a lie i don't think i'd be able to hide what i know and secondly bc it seems like a better way of maintaining the boundaries? basically i'd just reiterate what i knew/thought i knew and ask for corrections/their perspective and then ask how they feel about me knowing that about them. if that makes sense?

[comingatthecottage]

considering that galina does have role in the narrative with what you mentioned "driving a wedge between shane and ilya," do you wish they'd change the therapy aspects in s2? i.e. making galina more... professional and competent lmao. because RR clearly didn't intend for galina to be a bad therapist, because then that would've looked entirely different, right? (maybe. i don't know how much faith i have in RR when it comes to things like this)

i think it would be just fine to make her more professional and competent! i don't think her incompetence is intended to be a major driving force in the narrative (bc i think RR does actually believe that shane has things soooo easy and is being callous towards ilya, i think she takes galina's perspective here!) and because we're talking about a pretty complex case over a period of just a few months, even a terrific therapist wouldn't necessarily expect to see a meaningful improvement in symptoms over that period of time, so it wouldn't interfere w the fact that ilya is getting worse.

honestly i think it would be soooo juicy and interesting tho to dive into her being a bad therapist, but i understand the way i would like ilya's mental health issues to be treated are tonally inappropriate for the show, so probably it'd be better to make her a good therapist instead. i don't think they should have her be a bad therapist who's presented as though she were a good therapist.

[comingatthecottage]

Loved your Galina post. Wondering, do you have any fic recs that touch on therapy? Either in a more accurate depiction, or even just engaging in the topic in an interesting way. Similarly, I read two head injury fics by scarlettroses who clearly has a background in neuro and knows their stuff, absolutely fascinating, realistic look at TBIs. I'm ravenous for fics that engage in this space thoughtfully.

oh i wish i did! honestly i have not seen any fics in this fandom that i think do a good job representing therapy. the greatest therapy fic of all time to me will always be (fighter) (still) (remains) which is a Leverage trauma recovery fic. god i love this fic so much, it has inspired me enormously as a writer. it also depicts several different therapy modalities for different characters!

in heated rivalry i'm afraid i don't have any. but i do love those fics by scarlettroses (especially Love You Til My Lungs Give Out is unforgettably beautiful and such a powerful depiction of navigating cognitive disability).

if i find any good recs or if anybody has them lmk!