re: ilya's terrible therapist
okay i think i'm obligated to say that although i am a mental health professional very obviously nothing i post on my heated rivalry tumblr is professional advice nobody sue me or anything. i should also probably caveat that i am coming from a very specific perspective: i'm a relational psychoanalyst; i have adjunctive training in several behavioral modalities but i believe very, very strongly in relational psychodynamic work as being THE thing. for patients with complex relational trauma (aka mr. ilya rozanov), i don't believe anything else can create lasting change. i also don't believe in the medical model of mental health. these are things about which reasonable people can, of course, disagree, so i'll try to separate out things i think she does WRONG vs things i think are missed opportunities to do well/what i would do differently
THINGS THAT ARE WRONG the biggest and worst: patient presents for therapy for first time despite significant treatment barriers. patient discloses that he believes he is depressed. patient has a first-degree relative who died by suicide. your next question, your very next question, is "are you thinking of killing yourself". you don't beat around the bush, you don't imply it, you don't wait until the patient volunteers. you must ask directly and you must do so before the patient leaves your office, because there is a huge and immediate risk that this appointment is someone's last cry for help before an attempt, and the odds of a depressed patient with a trauma history related to the suicide of a parent attempting suicide is fucking staggering. it is in my opinion malpractice not to even screen for suicidal intent at this first appointment ANYWAY, i do this for all patients and to not do it for someone with ilya's history is outrageously dangerous. life-threateningly incompetent care. lack of treatment planning: doesn't take a history or anything at the first appointment. jumps directly into talking about a horrific trauma (finding his mother's dead body). sometimes people do come in to a first session in an escalated state and have to begin directly with discussing whatever is happening at that moment, and then you meet them where they're at, but ilya arrives in a calm if slightly nervous state. she should have started by laying out what therapy would look like and beginning to build rapport, not immediately being like "so how about your mom's corpse". the way she makes the diagnosis of depression is bizarre. āI think you are depressedā. she doesn't clarify whether or not she's actually diagnosing him with depression under the medical model, explain what that means, or ask what it means to him to hear that. it's also MONTHS in, after he came in suspecting depression, that she makes this diagnosis (in the US it has to be in the first session generally for insurance purposes, different, also bad). no actual screening for symptoms, no psychoeducation about what it means to have depression, no sense of prognosis which clearly upsets the patient. it is so important to contextualize a diagnosis, both what the particular diagnosis is and what the act of diagnosing means. no differential diagnosis. she knows that ilya has experienced at least one criterion A trauma for PTSD (his mother's death) but does nothing to screen for symptoms. she doesn't ask how old his sexual partners he had when he was fourteen were to screen for sexual abuse. she doesn't rule out bipolar which is a must when diagnosing depression. she doesn't ask any questions about substance use or screen for potential neurodivergence or any of a million other things. she doesn't refer to medical for potential physiological contributors for a guy whose career is "getting hit really hard in the head".
no clear treatment plan or goals, and no sense of how therapy is going to work besidesā¦ talking? the only goal ilya really sets is "be good enough for my boyfriend," and although she (rightly) pushes back on that she doesn't help him identify an alternate goal. she also doesn't explain what therapy is going to be like or how it works or help him get on board with what the project of therapy is going to be. she seems unshaken when he misses five appointments in a row (if i had a passively suicidal patient miss five appointments in a row i would not be brushing that off, we would be having a good chat about what the barriers to treatment were). culturally incompetent care: they're part of the same minority group (Russian immigrants) across one axis of identity, but Galina is not a queer hockey player (or as far as we know queer at all). she minimizes and dismisses the discrimination ilya is likely to face in his career from coming out, including the fact that he could get deported to Russia, jumping to a CBT technique that asks him to imagine the worst case scenario without engaging at all with how it feels to be in this position or validating his fears. mental health professionals have an ethical obligation to educate themselves about their patients' identities and to listen first. "I could lose my job and be deported and jailed because of my sexual identity" is not a cognitive distortion, it is a terrifying reality. perhaps an unlikely reality, but it exists. trying to use cognitive therapies to "reframe" real experiences of discrimination is, flat-out, therapeutic abuse. she also should have explicitly responded to his fear that she would out shane when he's afraid to say shane's name, not obliquely implied that she knows they're both hockey players: "i want to let you know that confidentiality extends to anything and everything you tell me, except (reiterate legal carveouts). there are no circumstances under which i would disclose your partner's identity to anyone. if you want to use his name, i won't repeat it to anyone except when we're in this room" THINGS THAT ARE POOR THERAPEUTIC STYLE IN MY OPINION AND WHAT I WOULD DO BETTER #MYNARCISSISM lack of curiosity: she does not prompt him to reflect emotionally, even when there are very obvious entry points to do so to do so. i.e. ilya says he's glad his father is dead, which is a huge emotional disclosure that is very risky for a patient to make, especially in a first appointment because he might expect judgment. and she justā¦ asks a factual question about the timeline, rather than engaging with the emotional content in any way (as a relational analyst what i would do here is ask "what does it feel like to share that with me?", but i do not think any good therapist would like, change the subject away from the feeling)
she regularly offers direct opinions about/interpretations of things ilya says, very early in their therapeutic relationship. "that must have been very hard" in response to his father's expectations of him (which he interprets as being about sochi--he seems to hear 'it must have been hard for you to fail like that', which is, uh, bad!), "it's good that you had that," etc. in spite of the fact that he's already indicated a complex relationship with his family and himself that mean he might feel quite differently than someone else expects! was it good that he had hockey, or did it just create another burden on him and his relationship with his father, or is it somewhere in the middle? did his father's expectations feel hard? traumatizing? was he proud that so much was expected of him? when did he notice those feelings? just some questions i might ask. describing how ilya must feel about things closes off conversation. her affect and presentation in the session: ilya repeatedly notices her masking her reactions to things, like the fact that he became sexually active so young. i guess technically you're still allowed to be a blank slate style therapist, even though i don't know anyone who still does this. but if you're a blank slate, be a blank slate. don't let patients notice that you're hiding your reactions to things. so for instance i would approach that conversation by having whatever reaction i had and then saying, "you might notice i had a reaction to you saying that," and either asking the patient how they interpreted my reaction or asking them if they'd like to know what i'm thinking (and then how does it feel to know that i'm feeling concerned, etc, the relational field goes on forever). my way isn't the only way but if you're visibly swallowing reactions it's bad. she doesn't check in with ilya about how he's feeling about therapy and dismisses his fear that it's not working. tbh the only thing she says that i like is "i'm good, but i'm not that good," which IS something i might say. but she doesn't go from there, it becomes a way of dismissing his fears. i would have asked what it's like to have to tolerate such a slow and uncertain recovery process. does he think therapy can help? are there ways in which it has helped? how does it feel to talk about it? how does it feel to talk to me about it? bizarre attitude towards self-disclosure. she gives ilya next to no information about herself, which, again, is an old-fashioned but not per se wrong way to do it. just because i'm the relational yapper machine 3000 doesn't mean that every therapist needs to tell their patient anything about themselves. but she does self-disclose twice. she tells ilya that she's watching their season/is a hockey fan, and makes a weird comment that she also enjoys shopping as a coping mechanism but that bedsheets are more in her price range than sports cars. even though i'm the yappatron 3000 i would not choose to make these particular disclosures! admittedly if i had a famous patient and i knew about their career i would probably tell them that directly in the first session, i would not however make asides about it because now you're kind of creating a dual relationship. the bedsheets thing is weird bc you gotta keep a wiiiide birth around anything even quasi sexual, like don't invite a patient to imagine what your bed is like you weirdo. also finances are usually an inappropriate thing to self-disclose, because therapy is also a financial relationship! i would never joke about how a patient has more money than me (even though most of my patients have a lot more money than me), it seems likely to induce guilt and also to disturb the therapeutic frame around money which is hard to manage anyway
therapeutic interventions: i mean the biggest problem is that she doesn't really seem to have a consistent style or approach or anything. they just kind of chat. the things she does say areā¦ weird. she directly gives advice about what he should do in his relationship with Shane repeatedly. She doesnāt otherwise tell ilya what to do, which would actually be more appropriate--there's a place for giving depressed patients clear instructions imo. but she doesn't do that, she tells him what to do with his boyfriend which is far riskier because she's never met shane! the worst bit is that she also directly predicts what the outcome of one of the conversations she tells him to have will be, which isā¦ bad, because she does not know Shane, and this is like their fourth session, and she could be wrong. Thatās how you destroy a therapeutic rapport forever btw, is make a promise you canāt keep. i have never in my career assured a patient that a conversation they were gonna have with someone else would turn out well, because i don't know that person. maybe shane is an abusive asshole who is going to say "well if you're depressed just kill yourself already". she doesn't know this man!
her ideas about how to treat depression seem limited to pills and exercise. which is crazy because the man is a professional athlete. and she's like "well maybe go on a bike ride." because rachel reid clearly doesn't know how therapy works or what the mechanism of action is! she doesn't lay out the many, many possibilities ("i recommend speaking to a psychiatrist, options might include ssris or snris, other antidepressants, mood stabilizers, etc. there are also interventional methods like intravenous ketamine, transcranial magnetic stimulation, or ECT. i mention those only so you understand that there are a lot of options, and a lot of hope). she doesn't actually offer psychoed about lifestyle interventions--why exercise? what does nutrition look like? sleep? she tells him he needs to come out to his friends but doesn't offer anything to help him actually understand how social isolation and depression interact. she doesn't look at any of his strengths, notably the fact that he has a partner who adores him, that he has survived a lifetime of immense trauma, that he has a brilliantly successful career, etc. there's a stab at one CBT exercise but otherwise no concrete skills (again not my thing but it would be something). and no information about different therapy modalities and how they could potentially help him. okay that's the end of my essay sorry to anyone who doesn't care and had to watch this get reblogged like 8 separate times becasue tumblr was mad abt how long it was if anyone wants to know My Case Formulation of fictional character Ilya Rozanov and how i would Fix Him let me know @stunkbug here is the essay!
