Lars and the Real Girl
Steve Franklin, MSW, LCSW
6829 Gravois Ave
St. Louis, MO 63116
SteveFranklin@JUNO.com
www. Steve FranklinMSW.com
314-517-8383
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Difference between
“eccentricity” and “disordered”
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What kind of problem?
Mental illness, other or none?
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Does Lars need treatment?
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Doctor’s approach?
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Family and community response?
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Community Mental Health movement
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How do you think
you might have responded?
What is the problem?
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People will laugh
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Attachment to objects
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Doctor interview:
“ADL’s”? Violence? Psychosis?
DSM-IV
“The disturbance causes
clinically significant impairment
in social, occupational, or
other important areas of functioning.”
Differential
Diagnosis
Avoidant personality disorder?
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Social inhibition
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Feelings of inadequacy
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Extreme sensitivity to negative evaluation
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Feel socially inept, unappealing
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Excessively monitor reactions of people
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:
Panic disorder with agoraphobia
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Remains at home,
or in just a few comfortable places
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fear of having panic attack
Social Anxiety Disorder
Social Phobia?
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Persistent, intense, and chronic fear
of being judged by others and
of potentially being embarrassed or
humiliated by one's own actions.
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Physical symptoms often accompany social
anxiety disorder

including Panic attacks.
Asperger’s Disorder?
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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
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Asperger’s Disorder?
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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
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Asperger’s Disorder?
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They may be unusually sensitive or
insensitive to sound, light, touch,
texture, taste, smell, pain,
temperature, and other stimuli
Delusional Disorder
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Delusion that doesn’t fit another disorder
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Tactile or olfactory hallucinations if
related to theme
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Functioning and behavior otherwise normal.
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Ignore information that contradicts belief
Delusional Disorder
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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
Developmental analysis
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Lars afraid of manhood:
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Saw dad sad in the responsibility
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Note family difficulty in discussing emotion
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Recent change? Afraid of Karin’s childbirth
Developmental Analysis
Doctor:
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“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
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Jungian
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Bianca as anima,
the projection of disowned female self
projection of disowned idealized self
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Missionary, Doesn’t care about superficial things, Can’t
have babies (or die in childbirth),Has nurse’s training
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Like him: left-handed; her mom died; God made her to help
people; Doesn’t feel sorry for self-just wants to be normal..”
Treatment
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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?
Treatment
Typical approaches:
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Antipsychotic and antidepressant
medication
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Cognitive-behavioral therapy top help
challenge the delusion.
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Insight-oriented therapy: develop a sense
of creative doubt in the internal perception
of the world
Treatment
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Community can provide support and
encourage the patient to regain his or her
abilities.
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If goals not seen as attainable, person
feels pressured/criticized, probably
increasing stress… worsening of symptoms.
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Avoiding direct confrontation of the
delusional symptoms (When confronted by
brother, Lars simply doesn’t hear.)
Disability: Embracing strength
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Minister: “From her wheelchair, Bianca
reached out and touched us all.. “
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(Lars sees her “difference” as an
expression of her disability.
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It’s not that Bianca was artificial.
She was just. “Realness challenged”)
Community
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Finds ways for Bianca to contribute
in ways she can be
helpful/productive… model, help at
nursing home.
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They project themselves: they
believe that Bianca, like them, would
want to help
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.”