Lars and the Real Girl

1. Lars and the Real Girl Steve Franklin, MSW, LCSW6829 Gravois Ave St. Louis, MO 63116SteveFranklin@JUNO.comwww. Steve FranklinMSW.com 314-517-8383

2. Difference between “eccentricity” and “disordered” • What kind of problem? Mental illness, other or none? • Does Lars need treatment? • Doctor’s approach?

3. Family and community response? • Community Mental Healthmovement • How do you think you might have responded?

5. What is the problem? • People will laugh • Attachment to objects • Doctor interview: “ADL’s”? Violence? Psychosis?

6. DSM-IV “The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.”

7. Differential Diagnosis

8. Avoidant personality disorder? • Social inhibition • Feelings of inadequacy • Extreme sensitivity to negative evaluation • Feel socially inept, unappealing • Excessively monitor reactions of people

9. Schizoid personality disorder? Lack of interest in social relationships • Solitary, secretive, and emotionally cold • Little interest in having sexual experiences • takes pleasure in few, if any, activities • lacks close friends or confidants other than first-degree relatives • appears indifferent to praise/criticism • “Dependency and love are dangerous” Psychodynamic Diagnostic Manual:

10. Panic disorder with agoraphobia • Remains at home, or in just a few comfortable places • fear of having panic attack

11. Social Anxiety Disorder Social Phobia? • Persistent, intense, and chronic fear of being judged by others and of potentially being embarrassed or humiliated by one's own actions. • Physical symptoms often accompany social anxiety disorder • including Panic attacks.

12. Asperger’s Disorder? • Involves an impairment in social interaction Such as • impaired in the use of multiple nonverbal social behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction • failure to develop peer relationships • lack of social or emotional reciprocity

13. Asperger’s Disorder? • B.Restricted repetitive and stereotyped patterns of behavior, interests, and activities • preoccupation with an area of interest that is abnormal either in intensity or focus • Adherence to routines, rituals • Stereotyped/repetitive mannerisms • Preoccupation with parts of objects

14. Asperger’s Disorder? • They may be unusually sensitive or insensitive to sound, light, touch, texture, taste, smell, pain, temperature, and other stimuli

15. Delusional Disorder • Delusion that doesn’t fit another disorder • Tactile or olfactory hallucinations if related to theme • Functioning and behavior otherwise normal. • Ignore information that contradicts belief

16. Delusional Disorder • Types :erotomanic, grandiose, jealous, persecutory, somatic, … and unspecified. • Psychodynamic: protective response to stress • Behaviors’ Extremeness/inappropriateness rather than the simple truth or falsity of the belief, indicate its delusional nature

17. Developmental analysis • Lars afraid of manhood: • Saw dad sad in the responsibility • Note family difficulty in discussing emotion • Recent change? Afraid of Karin’s childbirth

18. Developmental Analysis Doctor: • “He’s been decompensating for some time.” • “Mental Illness can be a communication, a way to work something out.” • Compensate for lack of a mother/ father’s distance/blaming.  • Embraces his loneliness/withdrawal • Others’ need for connection is weakness.  • Karin’s pregnancy arouses unconscious loss/abandonment feelings

19. Jungian • Bianca as anima, the projection of disowned female self projection of disowned idealized self • Missionary, Doesn’t care about superficial things, Can’t have babies (or die in childbirth),Has nurse’s training • Like him: left-handed; her mom died; God made her to help people; Doesn’t feel sorry for self-just wants to be normal..”

20. Treatment • Is his “difference” something to be treated or pathologized? • Lars doesn’t seem to experience being treated so much as being in relationship. • Ethics of doctor’s approach?

21. Treatment Typical approaches:  • Antipsychotic and antidepressant medication • Cognitive-behavioral therapy top help challenge the delusion. • Insight-oriented therapy: develop a sense of creative doubt in the internal perception of the world

22. Treatment • Community can provide support and encourage the patient to regain his or her abilities. • If goals not seen as attainable, person feels pressured/criticized, probably increasing stress… worsening of symptoms. • Avoiding direct confrontation of the delusional symptoms (When confronted by brother, Lars simply doesn’t hear.)

23. Disability: Embracing strength • Minister: “From her wheelchair, Bianca reached out and touched us all.. “ • (Lars sees her “difference” as an expression of her disability. • It’s not that Bianca was artificial. She was just. “Realness challenged”)

24. Community • Finds ways for Bianca to contribute in ways she can be helpful/productive… model, help at nursing home. •  They project themselves: they believe that Bianca, like them, would want to help

25. Community Minister in church scene: “There really is only one law.. the lord has told us what to do: Love one another. That, my friends, is the one true law.”