Lars and the Real Girl
Steve Franklin, MSW, LCSW
6829 Gravois Ave
St. Louis, MO 63116
[email protected]
www. Steve
Difference between
“eccentricity” and “disordered”
What kind of problem?
Mental illness, other or none?
Does Lars need treatment?
Doctor’s approach?
Family and community response?
Community Mental Health movement
How do you think
you might have responded?
What is the problem?
People will laugh
Attachment to objects
Doctor interview:
“ADL’s”? Violence? Psychosis?
“The disturbance causes
clinically significant impairment
in social, occupational, or
other important areas of functioning.”
Avoidant personality disorder?
Social inhibition
Feelings of inadequacy
Extreme sensitivity to negative evaluation
Feel socially inept, unappealing
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
Remains at home,
or in just a few comfortable places
fear of having panic attack
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.
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
Asperger’s Disorder?
B.Restricted repetitive and stereotyped
patterns of behavior, interests, and
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
Asperger’s Disorder?
They may be unusually sensitive or
insensitive to sound, light, touch,
texture, taste, smell, pain,
temperature, and other stimuli
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
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
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
Developmental Analysis
“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
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..”
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?
Typical approaches:
Antipsychotic and antidepressant
Cognitive-behavioral therapy top help
challenge the delusion.
Insight-oriented therapy: develop a sense
of creative doubt in the internal perception
of the world
Community can provide support and
encourage the patient to regain his or her
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.)
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”)
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
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.”