Steve Franklin, MSW, LCSW6829 Gravois Ave St. Louis, MO 63116

SteveFranklin@JUNO.com www. Steve FranklinMSW.com

314-517-8383

Lars and the Real Girl

Difference between Difference between ““eccentricity” and “disordered”eccentricity” and “disordered”

What kind of problem? What kind of problem? Mental illness, other or none?Mental illness, other or none?   Does Lars need treatment?Does Lars need treatment?

Doctor’s approach?Doctor’s approach?

Family and community response?Family and community response?

   Community Mental HealthCommunity Mental Health

movementmovement

How do you think How do you think

you might have responded?you might have responded?

What is the problem?What is the problem?

People will laughPeople will laugh

Attachment to objectsAttachment to objects

Doctor interview: Doctor interview:

““ADL’s”? Violence? Psychosis?ADL’s”? Violence? Psychosis?

DSM-IVDSM-IV

““The disturbance causes The disturbance causes

clinically significant impairmentclinically significant impairment

in social, occupational, or in social, occupational, or

other important areas of other important areas of functioning.” functioning.”

DifferentialDifferential

DiagnosisDiagnosis

Avoidant personality Avoidant personality

disorder?disorder?

   Social inhibitionSocial inhibition   Feelings of inadequacyFeelings of inadequacy

Extreme sensitivity to negative evaluation Extreme sensitivity to negative evaluation

Feel socially inept, unappealingFeel socially inept, unappealing   Excessively monitor reactions of people Excessively monitor reactions of people

Schizoid personality Schizoid personality disorder?disorder?

Lack of interest in social relationshipsLack of interest in social relationships Solitary, secretive, and emotionally coldSolitary, secretive, and emotionally cold Little interest in having sexual Little interest in having sexual

experiencesexperiences takes pleasure in few, if any, activitiestakes pleasure in few, if any, activities lacks close friends or confidants other lacks close friends or confidants other

than first-degree relativesthan first-degree relatives appears indifferent to praise/criticism appears indifferent to praise/criticism ““Dependency and love are Dependency and love are dangerous”dangerous”

Psychodynamic Diagnostic ManualPsychodynamic Diagnostic Manual::

Panic disorder with Panic disorder with agoraphobiaagoraphobia

Remains at home, Remains at home,

or in just a few comfortable placesor in just a few comfortable places

fear of having panic attack fear of having panic attack

Social Anxiety Disorder Social Anxiety Disorder Social Phobia?Social Phobia?

   Persistent, intense, and chronic fear Persistent, intense, and chronic fear    of being judged by others and of being judged by others and of potentially being embarrassed or of potentially being embarrassed or

humiliated by one's own actions.humiliated by one's own actions. Physical symptoms often accompany social Physical symptoms often accompany social

anxiety disorder anxiety disorder    including Panic attacks. including Panic attacks.

Asperger’s Disorder?Asperger’s Disorder?

Involves an impairment in social Involves an impairment in social interaction interaction Such asSuch as

impaired in the use of multiple nonverbal impaired in the use of multiple nonverbal social behaviors social behaviors such as eye-to-eye gaze, facial such as eye-to-eye gaze, facial expression, body postures, and gestures expression, body postures, and gestures to regulate social interactionto regulate social interaction

failure to develop peer relationshipsfailure to develop peer relationships lack of social or emotional reciprocity lack of social or emotional reciprocity

Asperger’s Disorder?Asperger’s Disorder?

B.Restricted repetitive and stereotyped B.Restricted repetitive and stereotyped patterns of behavior, interests, and patterns of behavior, interests, and activitiesactivities

preoccupation with an area of interest preoccupation with an area of interest that is abnormal either in intensity or that is abnormal either in intensity or focusfocus

Adherence to routines, ritualsAdherence to routines, rituals Stereotyped/repetitive mannerismsStereotyped/repetitive mannerisms Preoccupation with parts of objectsPreoccupation with parts of objects

Asperger’s Disorder?Asperger’s Disorder?

They may be unusually They may be unusually sensitive or insensitive to sensitive or insensitive to sound, light, touch, texture, sound, light, touch, texture, taste, smell, pain, taste, smell, pain, temperature, and other stimulitemperature, and other stimuli

Delusional DisorderDelusional Disorder

Delusion that doesn’t fit another disorderDelusion that doesn’t fit another disorder

   Tactile or olfactory hallucinations if Tactile or olfactory hallucinations if

related to theme related to theme

   Functioning and behavior otherwise Functioning and behavior otherwise

normal. normal.

   Ignore information that contradicts belief Ignore information that contradicts belief

Delusional DisorderDelusional Disorder

Types :erotomanic, grandiose, jealous, Types :erotomanic, grandiose, jealous, persecutory, persecutory, somatic,somatic, … and unspecified. … and unspecified.

   Psychodynamic: protective response to stressPsychodynamic: protective response to stress

   Behaviors’ Extremeness/inappropriateness Behaviors’ Extremeness/inappropriateness

rather than the simple truth or falsity of the rather than the simple truth or falsity of the belief, belief, indicate its delusional natureindicate its delusional nature

Developmental analysisDevelopmental analysis

Lars afraid of manhood:Lars afraid of manhood:

   Saw dad sad in the responsibilitySaw dad sad in the responsibility

Note family difficulty in discussing emotionNote family difficulty in discussing emotion

   Recent change? Afraid of Karin’s childbirth Recent change? Afraid of Karin’s childbirth

Developmental AnalysisDevelopmental Analysis

Doctor: Doctor: ““He’s been decompensating for some time.”He’s been decompensating for some time.”     “ “Mental Illness can be a communication, a Mental Illness can be a communication, a

way to work something out.” way to work something out.” Compensate for Compensate for lack of a mother/ father’s distance/blaming. lack of a mother/ father’s distance/blaming.  Embraces his loneliness/withdrawalEmbraces his loneliness/withdrawal Others’ need for connection is weakness. Others’ need for connection is weakness.  Karin’s pregnancy arouses unconscious Karin’s pregnancy arouses unconscious

loss/abandonment feelingsloss/abandonment feelings

JungianJungian

Bianca as Bianca as animaanima, , the projection of disowned female selfthe projection of disowned female selfpprojection of disowned idealized selfrojection of disowned idealized self

Missionary, Doesn’t care about superficial things,Missionary, Doesn’t care about superficial things, Can’t Can’t have babies (or die in childbirth),Has nurse’s traininghave babies (or die in childbirth),Has nurse’s training

Like him: left-handed; her mom died; God made her to Like him: left-handed; her mom died; God made her to help people; Dhelp people; Doesn’t feel sorry for self-just wants to be oesn’t feel sorry for self-just wants to be normal..” normal..”

TreatmentTreatment

Is his “difference” something to be Is his “difference” something to be treated or pathologized?treated or pathologized?

   Lars doesn’t seem to experience being Lars doesn’t seem to experience being

treated so much as being in relationship.treated so much as being in relationship.

Ethics of doctor’s approach?Ethics of doctor’s approach?

TreatmentTreatmentTypical approaches: Typical approaches: 

Antipsychotic and antidepressant medicationAntipsychotic and antidepressant medication   Cognitive-behavioral therapy top help Cognitive-behavioral therapy top help

challenge the delusion. challenge the delusion.    Insight-oriented therapy: develop a sense of Insight-oriented therapy: develop a sense of

creative doubt in the internal perception of creative doubt in the internal perception of the world the world

TreatmentTreatment Community can provide support and Community can provide support and

encourage the patient to regain his or her encourage the patient to regain his or her abilities. abilities.

If goals not seen as attainable, person feels If goals not seen as attainable, person feels pressured/criticized, probably increasing pressured/criticized, probably increasing stress… worsening of symptoms. stress… worsening of symptoms.

   Avoiding direct confrontation of the Avoiding direct confrontation of the

delusional symptoms (When confronted by delusional symptoms (When confronted by brother, Lars simply doesn’t hear.)brother, Lars simply doesn’t hear.)

Disability: Embracing Disability: Embracing strengthstrength

Minister: “From her wheelchair, Bianca Minister: “From her wheelchair, Bianca reached out and touched us all.. “ reached out and touched us all.. “

   (Lars sees her “difference” as an (Lars sees her “difference” as an

expression of her disability. expression of her disability.

   It’s not that Bianca was artificial. It’s not that Bianca was artificial.

She was just. “Realness challenged”)She was just. “Realness challenged”)

CommunityCommunity Finds ways for Bianca to contribute Finds ways for Bianca to contribute

in ways she can be in ways she can be helpful/productive… model, help at helpful/productive… model, help at nursing home. nursing home.

  They project themselves: they They project themselves: they believe that Bianca, like them, believe that Bianca, like them, would want to help would want to help

CommunityCommunityMinister in church scene: Minister in church scene:

““There really is only one law.. There really is only one law..

the lord has told us what to do: the lord has told us what to do:

Love one another. Love one another.

That, my friends, is the one true That, my friends, is the one true law.”law.”