Film Review by Harry Karlinsky, MD, MSc, FRCPC
Clinical Professor, Department of Psychiatry, UBC, Coordinator, Medical Education/Professional Development, Richmond Mental Health Services; and Franny Karlinsky, BA
USA, 2007, Director: Craig Gillespie
Released in 2007, Lars and the Real Girl, the directorial debut of Craig Gillespie achieved a surprisingly successful reception for a small independent production.
The film revolves around the life of 27-year-old Lars Lindstrom, a quiet, sensitive and vaguely awkward young man who lives in a converted garage beside the home of his older brother Gus and pregnant sister-in-law Karin.
Despite Gus’ and Karin’s genuine efforts to engage Lars, he instead isolates himself from any real involvement with his family and his small town middle-America community.
Early scenes suggest that he appears to function reasonably well at work and in other day-to-day activities. It isn’t until Lars abruptly introduces his girlfriend Bianca, a life-size anatomically correct doll he secretly purchases off the Internet that Gus and Karin (and the viewer) realize the extent of Lars’ disconnection from reality. To Lars, Bianca is anything but a sex-toy. She is a paraplegic missionary of Brazilian and Danish descent, and Lars is deeply in love with her.
From a psychiatric perspective, it’s not hard to recognize that Lars has a real problem as opposed to a real girl.
On the ruse that they are concerned about Bianca’s health, Gus and Karin arrange an appointment for Bianca to be seen by Dagmar, the local family physician. After examining Bianca and indirectly Lars, Dagmar concludes that Lars “appears to have a delusion” but she does not believe he is “psychotic or schizophrenic” nor does she believe Lars has a “mental illness”.
Although it would be hard to reconcile the presence of a delusion without diagnosing psychosis in DSM-IV-TR, what is more interesting than the working diagnosis is how the delusion is managed.
The concerned brother and sister-in-law are advised to “go along with it!”, as does Dagmar herself.
Weekly appointments are set up for Bianca to have her blood pressure monitored. Most remarkably, the exhortation to “go along with it” is respectfully embraced by Lars’ entire community.
Not only does Bianca become a patient, she begins attending church, accompanies Lars to an office party, accepts a part-time job as a mannequin, volunteers at the local hospital, and is even elected to the school board!
Unfortunately like other real girls, Bianca can also become ill. Despite emergency treatment at the local hospital, she ultimately dies in Lars’ arms. Bianca is buried in the local cemetery and her loss is mourned by the entire community.
As bizarre as the above story line must sound, it somehow works magnificently. This is in no small measure to the acting abilities of Canadian-born Ryan Gosling as Lars, who somehow maintains a remarkably controlled and consistent tone of genuine love and serenity throughout the film, despite his unusual choice of love-object.
The community’s respectful response to Bianca becomes an inspiring lesson in non-judgmental acceptance. And what could have easily degenerated into a series of lewd sex jokes and slapstick humor emerges as a gentle, understated, and thoughtful film.
Although the unconditional acceptance of Lars’ delusion makes for an intriguing story line, it seems likely that Lars’ delusion would be managed far differently by most psychiatrists today.
As one illustrative example, a more traditional approach emerges in the case discussion provided by Thomas McGlashan with respect to another man preoccupied with a delusion.
Dr. McGlashan counsels that, in the first instance, “the reality of the delusion should neither be accepted nor argued, and observations should be offered as hypotheses.”
Dr. McGlashan goes on to suggest that once a working relationship is established, more active modalities such as medication and cognitive behavioural techniques can then be introduced.
The immediate and remarkable acceptance of Lars’ delusion is obviously one point of dissonance from therapeutic orthodoxy; the introduction of medications was also apparently never considered by Dagmar.
Nevertheless, it is noteworthy that not just medications are now considered a potential therapeutic intervention for delusions. As summarized by Daniel Freeman and Philippa Garety, a remarkable transformation with respect to how delusions are conceptualized and treated is now underway within psychiatry.
Delusions are no longer simply dismissed as ‘ununderstandable’, heretofore a perspective that seems to have become the dominant one with the recent rise of the biological era and antipsychotic medications. Instead, it is now recommended that most patients be allowed the opportunity to talk about their delusional belief systems and that these may respond to cognitive behavioural techniques (as alluded to by Dr. McGlashan above), particularly when medications accompany this approach.
In returning to Lars and the Real Girl, Dagmar’s intervention now no longer seems quite so unconventional. By creatively utilizing Bianca as the identified patient, Dagmar was also able to see Lars on a weekly basis, and thereby establish an empathic, supportive, and at times, even an appropriately confiding relationship.
Although cognitive behavioural techniques were not undertaken, except to desensitize Lars to his intense fear of being touched, viewers did see a gentle psychodynamic treatment in action. In a paper discussing psychodynamic approaches to delusional disorder, Elizabeth Loula states, “From the psychodynamic point of view, delusions and psychotic symptoms exist for a reason.”
This functionality was immediately assumed by Dagmar who explicitly understood Bianca as a “communication” and a way for Lars “to work something out”. Although never spelled out explicitly in the film, it is clear Bianca is a safe companion for Lars, a lonely young man who both desires intimacy and yet is terrified of it. However, by the end of the film, it is Lars who eventually declares Bianca ill and, in a touching scene, her death.
It is clear we are seeing the initial glimpses of a healthier Lars emerging, including a new capacity to establish a more mature relationship with Margo, a real female co-worker who patiently stood by Lars throughout his relationship with Bianca.
In addition to reintroducing our profession to a psychodynamic approach to delusions (and yes, the appropriate evidence-based research with respect to efficacy in the real world is required), Lars and the Real Girl also usefully draws attention to what happens beyond a clinician’s own limited interactions with his or her delusional patient. It’s not hard to imagine that in most communities Lars would have been mercilessly ridiculed by a significant number of ill-informed members of the public.
And although there is no systemic data on lay challenges, gentle or vigorous, to delusions, P.J. Taylor has mused there may be a link between such challenges and subsequent violent acts by the delusional individual.
Therefore, it might be argued that, at least in some circumstances, accepting or “going along with” a delusion, might be a better, or at least more expedient alternative to challenging certain types of delusions. Especially when a more neutral position cannot be established or the subjective experience validated.
This might particularly be the case for strangers who are obviously in no position to establish a long-term therapeutic relationship with the delusional individual within which the delusion might be explored.
Of course, there are all sorts of concerns about colluding with delusions as well, including ethical issues around deception, the implication that treatment is not necessary, the importance of reality-testing, and also, whether the act of accepting delusions might contribute to a refractory status and, indeed, violence itself, depending upon the content of the delusion.
The implication of this dilemma for mental illness first aid courses or crisis intervention training does not appear to be trivial.
In Lars and the Real Girl, the Hollywood happy ending triumphs. In the real world, the different therapeutic skills required by clinicians, family, friends and the community to best help those like Lars still call for further reflection and study.
1. McGlashan, T. H. “Under Surveillance”, in R.L. Spitzer et al. (eds), Treatment Companion to the DSM-IV-TR Casebook. Washington, DC: American Psychiatric Publishing, Inc., pp. 222-231, 2004.
2. Freeman, D., Garety, P.A. “Delusions”, in J.E. Fisher and W.T. O’Donohue (eds), Practitioner’s Guide to Evidence-Based Psychotherapy. New York, NY: Springer Science + Business Media, pp. 205-213, 2006.
3. Silva, S.P., Kim, C.K., Hofmann, S.G. and Loula, E.C. To believe or not to believe: Cognitive and psychodynamic approaches to delusional disorder, Harvard Review of Psychiatry 11(1):20-29, 2003.
4. Taylor, P.J. Delusional disorder and delusions: Is there a risk of violence in social interactions about the core symptom?, Behavioral Sciences & the Law 24(3):313-331, 2006.