13 Thoughts on 13 Reasons Why

**WARNING: SPOILERS APPEAR IN THIS POST.**

I watched the new Netflix series 13 Reasons Why (based on a book with the same title). This post sums up my reactions, and I am also in the process of recording detailed Jedi Counsel podcast episodes on the series with my co-host. Some people say this is art and entertainment, and therefore, exempt from social responsibility. Nonetheless, many people will watch this series, and that makes it important to view it critically and to consider its implications. My thoughts aren’t fully formed yet, but I wanted to post something as the series came out without waiting until I had it all sorted out. My feelings and opinions may develop more as I process the material for a longer period of time. I’m open and curious about other perspectives.

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  1. The series is set up as a mystery that quickly pulled me into the story. I finished the whole series within a few days. The framework for the series is that an adolescent, Hannah Baker, has died by suicide and left behind audio tapes detailing every component that she believes led up to her death. In addition, she has a methodical plan for the specific people who should listen to the tapes, how they should be listened to, and the order in which people hear them. While this is a compelling way to reveal a mystery, I believe that it contributes to stigma by painting the picture of a woman who ended her life for the purposes of getting attention from the individuals she believed ruined her life. The tone of her delivery is blaming and feels vengeful. I worry this perpetuates the myth that suicide is typically driven by desire for attention, selfishness, or revenge…which it most certainly is not.
  2. There is a scene that is explicitly blaming of one of the few kind (though not perfect) people in the series (Hannah’s friend and love interest, Clay). Hannah’s friend, Tony, tells Clay that Hannah would have been alive if he had acted differently. He later softens his tone, saying it is not Clay’s fault and Hannah is responsible for the choice that she made. Still, the blame message is there in a scene where Hannah tells Clay repeatedly to leave her alone. He reluctantly leaves the room. The show then depicts a parallel universe where the “right” things happened: Clay insists on staying despite Hannah clearly asking him to leave her alone, he turns the conversation around through persistence, Hannah feels loved, and suicide is prevented. In light of the violations of consent elsewhere in the series (including two rape scenes), I was bothered by Clay being painted as having done the wrong thing when he honored Hannah’s wishes to leave her alone.
  3.  Hannah decides, as her last attempt at help-seeking, to reach out to her school counselor about her suicidal thoughts and being the victim of rape. The counselor, insensitively and against best practice guidelines, implies she may be partially to blame (e.g., asking if she verbally said no to the perpetrator, asking if she had been drinking) and jumps right into telling her that her only choices are to: 1) report the assault or 2) to move on. She leaves the office, and he doesn’t follow-up with her in any way. He doesn’t ask for more details or conduct a suicide risk assessment, and he does not try to reach out to her parents to prevent her from harming herself. Of course, there are some counselors out there who might act in this irresponsible way. However, the vast majority would not. In a show that is viewed by a lot of young people, the depiction of the counselor matters a lot. People are already reluctant to reach out to mental health professionals. I worry people would feel even more discouraged from seeking help after seeing this terrible, judgmental, unethical interaction.
  4. The series accurately portrays some of the risk factors for suicide: social isolation, loneliness, and disconnection from others (including in the painful forms of bullying), perceiving herself as a burden (e.g., she describes herself as a “problem” for her parents and especially feels burdensome after accidentally losing some of their money), family conflict (her parents argue about issues including finances), witnessing and then being a victim of sexual assault, and hopelessness about her future (e.g., with regard to college and other plans).
  5. I appreciated the series emphasizing how crucial social connections are for health and talking about different types of loneliness – including individuals truly isolated and those who feel “lonely in a crowd.” It seemed to make the point that even apparently popular people (like Zack) can feel lonely. I believe this sends the message that anyone is vulnerable to loneliness, and we shouldn’t assume people are doing well just because they appear that way on the outside.
  6. One of the themes of the series is that – at any point – one person listening, reaching out, or doing something differently could have prevented Hannah’s suicide. Ultimately, this is a positive message. Unfortunately, I think it’s lost and distorted because it is used to blame people for their failures to save Hannah rather than demonstrating that one person could have made a difference and changed the story to a hopeful one. If the counselor or one of her parents had connected with Hannah and supported her in seeking help for her struggles, this point would have been much more persuasive. Instead, the story feels more demoralizing than inspiring to me.
  7. Hannah’s death scene is a graphic depiction of her cutting her wrists with razorblades in a bathtub. In a documentary-type episode made about the series, they said that it was to show the painful and hard-to-look-at nature of suicide. To me, it feels like a choice to make a dramatic, visually startling conclusion to the story rather than to deliver a lesson. It makes sense – this is a series meant to be watched and to get people glued to their screens- not a PSA. It’s possible that an individual who feels suicidal might see that and be afraid; however, it’s also quite plausible that an individual feeling suicidal might mistakenly view it as an end to all of Hannah’s emotional pain and problems. Anecdotally, there are cases of suicidal individuals watching scenes of suicide building up to taking their own life.
  8. There are warnings in the beginnings of episodes where there are graphic scenes (e.g., sexual assault, suicidal behavior). It would have been helpful if the episodes had information about resources, such as the National Suicide Prevention Lifeline and the American Foundation for Suicide Prevention, embedded in them too. It would be a simple way to reach a lot of people. Again, the series created a separate short documentary-like episode with mental health professionals and resources in it. However, it appears completely separately from the series (rather than as the 14th episode, for example). It would reach more people if it was connected to the full series.
  9. The pain Hannah’s parents experience after her death is excruciating. I feel this is one of the most realistic aspects of the series. It shows their horror, their confusion, their regret, and their desire to prevent other suicides from occurring. In the documentary afterwards, they suggest that this might show individuals who feel suicidal about the pain that others would experience if they died. I think this may be the case for some, but for certain individuals, tragically, they might imagine that people wouldn’t feel the same way about their death. That’s the cruelty of perceiving oneself as a burden – people struggling with mental health problems may not see how the world is better with them in it.
  10. Related to the second point, several characters clearly violate Hannah. Marcus and Bruce grab her, Tyler and Justin take and share revealing pictures without permission, and Bryce rapes her. When Hannah and Clay are starting to kiss, Clay asks, “Is this okay?” I really liked this scene because it shows how asking about consent is natural and enhances, rather than ruins, the moment. It also shows a welcome contrast in that Clay genuinely respects and cares about her feelings and perspective. Sadly, this positive point gets diminished when the scene turns into Hannah yelling for him to “get the hell out” and the suggestion that if he had only ignored her wishes, he would have saved her life (as described above).
  11. From one perspective, it seems like a point of the series is to teach bullies that their actions can lead to someone dying by suicide. However, most people who are bullied do not die by suicide – people are often remarkably resilent in the face of great adversity. It’s important that people who are on the receiving end of bullying know that. Secondly, most of the people on Hannah’s tapes are more concerned about protecting their own secrets (e.g., that Courtney is attracted to women, that Justin allowed Bryce to rape Jessica, that Ryan published Hannah’s poem without her permission) than how they hurt Hannah. If the message is supposed to be an anti-bullying one, I don’t think it really connects with bullying people in the audience. I guess that it would resonate more with people on the receiving end of bullying who feel a sense of hopelessness about the bullies having any potential for empathy and a sense that there is no help available to them.
  12. On two occasions, two adults (the counselor and the communications teacher) state that the warning signs for suicide include withdrawing from friends and family, changes in appearance, and trouble in group projects. This was a great opportunity to share the real warning signs for suicide, but unfortunately, only the first one really maps onto the list.
  13. A lighthearted, sweet aspect of the series is that Clay is different from his peers in that he cares relatively less about what other people think of him. He still cares what people, including Hannah, think of him to some extent, but he doesn’t try as hard as his peers to be something he’s not. He feels nervous around Hannah, but doesn’t ever really pretend to be someone else. He doesn’t let other people’s opinions make him feel bad about himself. Again, Clay’s not perfect (he says some mean things to Hannah and looks at a revealing picture that Tyler took without consent). But, overall, he’s smart, sensitive, caring, a good student, interested in the world beyond the walls of his school, helps others, takes reasonable caution in his decision-making, and likes geek stuff like Lord of the Rings and Star Wars. During one exchange, Hannah says to Clay, “Wow. You’re an actual nerd. There’s courage in that.” Most of the other characters in the series view themselves and their worth in terms of what their peers think of them. This generally rings true with regard to this developmental period in adolescence. It’s refreshing to see someone who has some self-acceptance and a sense of what’s right in the midst of all of the tragedy.

You can check out our first podcast episode on this series here and our second episode here.

If you or someone you know needs help, please reach out. There is hope and help is available here.

Dueling Personalities: The Psychology of the Hamilton-Burr Conflict

Note: Most of the words in this post are direct or slightly modified excerpts from the brilliant lyrics written by Lin-Manuel Miranda for the musical, Hamilton. This analysis is based on the portrayals of Burr and Hamilton in the musical.

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PSYCHOLOGICAL REPORT

Names: Aaron Burr, Alexander Hamilton
Ages: 48 (Burr), 47 (Hamilton)
Education: Bachelor’s degree from College of New Jersey/Princeton; theological, military, and legal training (Burr), Bachelor’s degree from King’s College/Columbia; military & legal training (Hamilton)
Date of Session: July 10, 1804
Therapists: Katie Gordon, Ph.D., Brandon Saxton, M.S.

Presenting Problem
Alexander Hamilton’s wife, Eliza, grew concerned when he said that he “had an early meeting out of town.” Hamilton’s disagreement with his long-time frenemy, Aaron Burr, had recently escalated, and she was suspicious that this meeting might actually be a duel. She insisted that Hamilton and Burr attend a therapy session to resolve their conflict peacefully. Eliza told him that she felt helpless after losing their son in a duel and that he owed it to her after burning her with the whole Reynolds Pamphlet ordeal. Hamilton couldn’t say no to this.

We started the session by walking up to the two men in the waiting room and asking one of them, “Pardon me, are you Aaron Burr, sir?” To which he responded, “Alexander Hamilton. My name is Alexander Hamilton.” After getting clarity on who was who, we introduced ourselves and invited them back to our office to further assess the problem. During the interview, we did not find Burr to be forthcoming on any particular stance. He’d glance off, obfuscate, and dance. Meanwhile, Hamilton did not equivocate on his opinion; he wore it on his sleeve.

Apparently, the heart of the conflict was that Burr wanted desperately to be in “the room where it happens” and blamed Hamilton for his losses in the Presidential election of 1800 and the New York Governor election in 1804. Specifically, Burr believed that Hamilton’s public attacks on his character swayed these elections. Hamilton’s criticisms of Burr included saying that he had no principles and acted in an opportunistic, self-interested fashion. He called him “amoral” and a “dangerous disgrace.”

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History
Burr’s grandfather was a fire and brimstone preacher; his mother was a genius; his father commanded respect. Tragically, both of his parents died when he was a young boy. When asked how he managed without them, he replied, “I’m a trust fund baby, you can trust me.” He was raised by relatives and reaped the benefits of their wealth, including access to an excellent education and connections with powerful people. After graduating in two years from college, he fought in the Revolutionary War. He was romantically involved with a married woman named Theodosia, whose husband was fighting on the British side in Georgia. Ultimately, he and Theodosia married (after her husband died) and had a daughter, who he referred to as “Dear Theodosia.” Burr practiced law and was active in politics as a Senator and Attorney General. The highest office he held was the Vice President of the United States from 1801-1805. The fact that Burr was born into financial and societal privilege may have influenced his life philosophy to wait patiently for opportunities to arise before acting on them. By working hard and avoiding huge public errors, he believed he could maintain the status and wealth he was born into and use them as a foundation to achieve even greater political power.

Hamilton presented as a bastard, orphan, son of a whore and Scotsman, dropped in the middle of a forgotten spot in the Caribbean by providence impoverished and squalor who grew up to be a hero and a scholar. When he was 10, his father split, full of it, debt-ridden; two years later, he and his mother were bed-ridden, half-dead sittin’in their own sick, the scent thick. Hamilton got better but his mother went quick. He moved in with a cousin, who died by suicide. Left to fend for himself, he got a job for his late mother’s landlord trading sugar cane and rum and all the things he couldn’t afford. By 14, he was in charge of a Trading Charter. Then, a hurricane came, and devastation reigned. He wrote a letter describing the hurricane’s impact, and it was so beautifully stated, that the people in his town took up a collection to send him to the mainland to get an education and nurture his talents. Like Burr, Hamilton graduated from college, fought in the Revolutionary War (Hamilton served as Washington’s right-hand man), practiced law, and was active in politics as the first Secretary of Treasury for the United States. He married Eliza Schuyler, after meeting her at a winter’s ball, and they had eight children together. Their oldest son, Philip, died at a young age in a duel. The fact that Hamilton was born into a stigmatized position at the time (i.e., being born out of wedlock) and into poverty may have influenced his life philosophy to persistently pursue his dreams without inhibition. By fervently seeking out chances to ascend in society and working non-stop, he believed he could attain status, wealth, and political power only by working a lot harder than others, by being a lot smarter than others, and by being more of a self-starter than others.

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Diagnostic Impressions
After an evaluation, we concluded that while Burr and Hamilton share many qualities, the areas where they differ led them to the point where they were considering a duel. An analysis of these overlapping and divergent qualities are depicted in the Venn diagram below:

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Treatment Recommendations
To our knowledge, there are not any evidence-based strategies for duel prevention. However, we intervened by explaining to Burr and Hamilton that participating in a duel would negatively impact them and interfere with their personal goals. We told Burr that killing Hamilton would hinder his ability to be in the room where it happens. We hoped that this would motivate him to find an alternative approach to handling the conflict. Similarly, we told Hamilton that duel participation would increase the likelihood that he would actually “run out of time” before establishing the legacy he desired, and we reminded him,”history has its eyes on you.”

We experienced resistance from Burr, who argued that he looked back on where he failed, and in every place he checked, the only common thread was Hamilton’s disrespect. His overwhelming blame of Hamilton for all of his thwarted plans formed a significant obstacle to duel dissuasion.

Similarly, Hamilton wasn’t willing to decline the duel invitation. Hamilton’s personality rarely involved backing down from positions or challenges. Indeed, when Burr asked him for an apology, Hamilton responded with, “Burr, your grievance is legitimate. I stand by what I said, every bit of it. You stand only for yourself. It’s what you do. I can’t apologize because it’s true.”

To this, Burr replied, “Then stand, Alexander. Weehawken. Dawn. Guns drawn.”

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Status at Follow-up
Burr shot Hamilton in a duel the day following our session, and Hamilton died the day after that. Hamilton’s legacy was planting seeds in a garden he’d never get to see. and he is remembered as a ten-dollar founding father, hero, and a scholar. Meanwhile, Burr became the villain in your history books. When Burr was asked if he had any regrets, he said that he now understood that “the world was wide enough for both Hamilton and me.” We would have strongly preferred that Burr had that revelation before killing Hamilton.

THE GORDON/SAXTON TEST

  1. Was the portrayal of mental illness accurate?

Lin-Manuel Miranda was not portraying characters with mental disorders. However, his depictions of Burr and Hamilton appear both psychologically and mostly historically accurate. Miranda went to great lengths to examine historical records and consult with historical experts when he created Hamilton. He took some artistic liberty for the sake of storytelling and this approach resulted in fascinating, relatable characters.

  1. Was the character struggling with mental health issues depicted with compassion?

Miranda depicted his characters with great compassion. Burr is generally remembered as a villain and Hamilton as a hero, but Miranda went beyond that simple dichotomy of good versus evil and presented two realistic characters with both redeeming and irritating qualities.

Overall rating: On a scale of Darwin Award to EGOT, we rate the Hamilton depictions of Burr and Hamilton as EGOT!

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The Room Where It’s Happening is an awesome Hamilton fan podcast! You can check it out here.

If you’d like to read 10 Hamilton Quotes for Therapists, you can click here.

We joined The Geek Therapy Podcast Network!

We have exciting news! We joined The Geek Therapy Podcast Network, which hosts 4 other shows: Geek Therapy (about the potential benefits of comics, games, TV shows, and movies), PsychTech (exploring the human side of technology), Headshots (about psychology and gaming), and Rolling for Change (about the educational and therapeutic side of gaming). We highly recommend all of these shows. They’re high quality, thoughtful, and super-fun to listen to! gtc

 

Wicked Smart Will Hunting

Name: Will Hunting
Age: 20
Education: Some high school
Occupation: Between jobs
Date of Report: December 5, 1997
Therapists: Katie Gordon, Ph.D., Brandon T. Saxton, M.S.

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Presenting Problem
Will was punching a man who had bullied him in kindergarten when three police officers showed up and tried to stop him. As they pulled Will away, he responded by kicking one of them. After Will appeared in court for this incident, the judge ordered a psychological evaluation. When Will arrived at our office, he made it clear that he was disinterested in meeting with us. He told us that he had read our website and listened to our podcast before coming in, and he was not impressed. He then lit a cigarette and told us to “go #$%&” ourselves. After being reminded that his timely release from jail was dependent on his cooperation with our evaluation, he said, “I’m pumped. Let the healing begin!”

Family/Social History
Will did not want to share his history with us, but we were able to obtain information from medical and court records. We learned that Will was an only child whose parents died when he was a young boy. He was then placed in the foster care system and was removed from three homes due to severe physical abuse (e.g., being stabbed with a knife and burned with cigarettes). Tragically, these early childhood experiences disrupted Will’s ability to form healthy attachments and trust people. He also developed a persistent fear that people would abandon him once they knew the truth about his past.

According to one of Will’s previous therapist’s notes, Will tended to act in an arrogant, cocky manner to push people away and protect himself from getting hurt. There were some exceptions to this pattern, however. Will had a close group of friends (including his best friend, Chucky) that he grew up with in South Boston (“Southie”). They spent time together driving around, watching local little league games, and hanging out at bars. He described them as “good guys” and “loyal.”

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Educational/Employment History
Will dropped out of high school due to disinterest, but actively pursued self-education through reading materials on a wide range of topics including history, chemistry, art, physics, and literature. He also chose to work as a janitor at MIT in order to gain more exposure to advanced mathematics. Based on Will’s verbalization and impressive knowledge, he appeared to have superior intellectual functioning. After explaining his educational history to us, Will stood up and looked at the diplomas and degrees on our walls and said, “You wasted $150,000 on an education you could’ve got for $1.50 in late fees at the public library.” He then made his way to our bookshelf, eyed a history book, and said, “If you want to read a real history book, read Howard Zinn’s A People’s History of the United States. That book will #$%&ing knock you on your #$%.” We thanked him for the advice and turned to his employment history, which consisted of working a string of different jobs including custodial work and construction.

Legal History
Will’s criminal records revealed the following charges: Assault (June, 1993; September, 1993), Grand Theft Auto*(February, 1994), Impersonating a Police Officer (January, 1995), Mayhem, Theft, and Resisting Arrest (dates unknown).

*He had this charge dropped by arguing that it fit within Free Property Rights of Horse and Carriage from 1798.

Diagnostic Impressions & Treatment Recommendations
Based on his presentation and behavior in Good Will Hunting (available on Netflix!), we decided to evaluate Will for antisocial personality disorder and posttraumatic stress disorder (PTSD). While he exhibited some PTSD symptoms in response to severe childhood abuse (e.g., persistent and exaggerated negative beliefs about oneself, others, or the world), he did not appear to meet full diagnostic criteria for the disorder (e.g., he did not appear to exhibit signs of recurrent, intrusive memories of the trauma).

According to the DSM-5, antisocial personality disorder is characterized by a pervasive pattern of disregard for and violation of the rights of others, occurring since age 15. Will clearly met at least 4 of the 7 criteria (3 are required for this diagnosis): 1) failure to conform to social norms with respect to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest (see legal history section), 2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure (e.g., lied about having 12 older brothers: Marky, Ricky, Danny, Terry, Mikey, Davey, Timmy, Joey, Robby, Johnny, and Brian; had Chucky pretend to be him during a job interview), 3) irritability or aggressiveness, as indicated by repeated physical fights or assaults (see presenting problem and legal history sections), and 4) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations (he quit at least two jobs without providing notice to his employers). While we can’t be completely certain that some of these behaviors were present by age 15, it seems reasonable to suspect that in light of his criminal record dating back to age 16.

A subset of individuals with antisocial personality disorder also exhibit psychopathic traits, including extreme callousness with regard to other people’s feelings. While Will displayed antisocial patterns, including criminal behavior, he did not appear to lack in conscience or concern for others. He experienced genuine and deep feelings for Skylar (a woman he dated) and his friends from Southie. Therefore, Will did not appear to be psychopathic. That is important for treatment planning, because there is evidence that individuals with psychopathy do not tend to improve or actually become worse with therapeutic intervention. Treatment research on antisocial personality disorder has not clearly identified effective treatments for this disorder. Most effective treatments for these types of behaviors target adolescents in family-focused, multicomponent treatments, which draws attention to the importance of early intervention for antisocial behavior.

Though he did not appear to meet criteria for PTSD, many of Will’s problems likely stem from, or were exacerbated by, tragic and traumatic childhood events. Therefore, he may benefit from a therapeutic approach that addresses the negative impact of these experiences while teaching him healthy emotional coping and behavioral strategies. Because this particular approach has not been scientifically-tested, his therapist should regularly monitor Will to ensure that he is receiving benefit from it. If he is not improving or becoming worse, this approach should be discontinued. Will has a number of strengths including his insight, knowledge, and desire for interpersonal connections – all which suggest that he may benefit from therapy, if he is willing to participate in it.

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Status at Follow-up
We contacted Will’s therapist, Sean Maguire, to follow-up on his status. Sean informed us that their therapy had a rough start, but they ultimately formed a strong, meaningful rapport and made substantial progress. Sean said that he last heard from Will through a letter that said he “had to see about a girl,” meaning that he had finally left his comfort zone in Southie and went to California so that he could continue his relationship with Skylar. We viewed this as a hopeful sign of progress for Will.

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THE GORDON/SAXTON TEST

  1. Was the portrayal of mental illness accurate?

Some aspects of antisocial personality disorder were accurate, as specified above. Will’s intellect is atypically high, and that fact is recognized with the fictional world of the movie.

  1. Was the character struggling with mental health issues depicted with compassion?

Yes, Will was written and portrayed as a nuanced and sympathetic character who effectively evoked compassion.

Overall rating:
On a scale of not liking them apples to very much liking them apples, we love them apples.

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AKA Jessica Jones & PTSD

PSYCHOLOGICAL REPORT

Name: Jessica Jones
Date of Birth into Comics: November, 2001
Education: High school diploma
Date of Initial Interview: 11/20/2015
Date of Report: 10/01/2016
Therapists: Katie Gordon, Ph.D., Brandon T. Saxton, M.S.

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Presenting Problems:
Jessica Jones was referred for a psychological evaluation by her sister, Patricia “Trish” Walker. Trish was concerned that Jessica was experiencing negative effects from the multiple traumatic events that had occurred throughout her life, including developing a drinking problem to cope with trauma-related stress. Trish expressed a belief that Jessica’s life would be much better if she received treatment, despite Jessica denying experiencing any problems at all. Jessica presented as very resistant for this interview, calling us “assholes” and maintaining that she would not waste her time whining to therapists.

Family/Social History:
Jessica Jones was the only daughter of Brian and Alisa Jones. She grew up with her parents and younger brother, Philip. Jessica was not a very social young woman, preferring to spend time alone and often expressing annoyance at others. Tragically, Jessica’s family was killed in a car accident. Jessica recalled that the accident was caused by her father’s distraction as she and her brother were fighting. It was clear that Jessica still blamed herself for this event.

After the death of her family, Jessica was adopted by Dorothy Walker, a talent agent. According to Jessica, Dorothy only adopted her as a publicity stunt to promote her daughter’s television show. Jessica’s new family and home life came with turmoil. Jessica would often overhear the Walkers fighting over Trish’s television show. Jessica stated that Dorothy put the show’s success above all else. She recalled seeing bruises on her sister’s neck, which she suspected were inflicted by Dorothy.

At one point, Jessica found Dorothy forcing Trish to vomit into a toilet in an attempt to make her lose weight. Jessica used her incredible strength to throw Dorothy across the room. Dorothy fled in terror, and this sparked the beginning of a closer friendship between the sisters.

Later in Jessica’s life, while toying with the idea of becoming a superhero, she met a man named Kevin Thompson, better known as Kilgrave. Kilgrave was experimented on as a child by his parents. They were hoping to treat his neurodegenerative disease but ended up giving him the ability to control people’s minds. He met and became fascinated with Jessica when he witnessed her overpowering some criminals to prevent a mugging.

Jessica spent the next few months under Kilgrave’s mind control. They stayed together in a motel room, and he commanded her to tell Trish that everything was fine whenever she would check on Jessica. Kilgrave felt that they were in an actual relationship, but Jessica identified the traumatic time as his forcing her to be with him with his power of controlling people. At one point, when Jessica had a few moments of free will, she contemplated jumping off of a building. Kilgrave found her and ordered her to step down from the ledge.

Later on, Kilgrave was trying to obtain a flash drive that contained evidence of his parents trying to treat his neurogenerative disease through experimental and painful methods. Kilgrave discovered that a woman had buried the flash drive under concrete. He commanded Jessica to dig it up, which took hours. Then, Kilgrave commanded Jessica to kill the woman. She punched her so hard in the chest that her heart stopped. Jessica stated that, after killing the woman, she was so distraught, she actually walked away from Kilgrave. While walking away, Kilgrave was screaming for her to come back, and he was hit by a bus. This ended his control over her. Jessica believed he was dead.

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Educational/Employment History:
Following high school, Jessica worked a few different jobs. The first was in an office. Jessica hated the position, stating that “This job was sucking my brains out through the air vent.” After a few weeks there, Jessica used her investigation skills to blackmail her boss. He was committing fraud, and Jessica leveraged this information into a six-month severance package in addition to a letter of recommendation.

Jessica’s next job was working at a sandwich shop. She wore a sandwich costume, handed out fliers, and hated the job. While passing out fliers on the street, Jessica saw a young girl run into the road. Springing into action, Jessica was able to use her powers to save the girl from being hit by a taxi. Hearing the gratitude in the girl’s voice, in addition to the urging of her sister, Jessica actually considered using her powers to become a superhero.

Ultimately, after the events involving Kilgrave, Jessica gave up on the notion of becoming a hero. Instead, she opened a private investigation firm called Alias Investigations. Jessica’s work at Alias often involved being hired by people who thought their romantic partners were having affairs, and she also helped locate missing people.

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Psychiatric/Medical History:
Jessica reported experiencing some prior psychiatric treatment from a therapist who taught her to recite her childhood neighborhood street names when experiencing posttraumatic stress disorder (PTSD) symptoms. She had a negative view of mental health services, reporting that her previous therapist was a “quack,” saying that she did not want to join a “group of whiners,” and “screw therapy.” Jessica also once had a physician prescribe her antipsychotic medications, claiming that she was paranoid. Another person stated that Jessica was “coming across as distinctly paranoid,” to which she responded, “Everyone keeps saying that. It’s like a conspiracy.” However, the physician and other person were incorrect in their assumptions about her being paranoid, because Jessica was, in fact, being stalked by Kilgrave. Beyond obtaining super-strength, near invulnerability, and remarkable jumping ability while hospitalized following her family’s car accident, Jessica denied any other significant medical history.

Assessment & Diagnostic Impressions:
All assessment information was gathered through behavioral observations (i.e., watching Jessica Jones on Netflix). Jessica’s symptoms were best captured by two diagnoses featured in the Diagnostic and Statistical Manual of Mental Disorders-5th Edition (DSM-5): PTSD and alcohol use disorder.

As mentioned above, Jessica directly experienced multiple traumatic events (defined by the DSM-5 as exposure to actual or threatened death, serious injury, or sexual violence). Jessica’s PTSD symptoms mostly related to her traumatic experiences with Kilgrave, which included rape, emotional abuse, and being subject to extremely controlling and manipulative behavior. For example, Jessica appeared to experience multiple intrusive symptoms, such as nightmares (e.g., she woke up crying after dreaming that Kilgrave licked her face) and flashbacks (e.g., she felt as if Kilgrave was talking to her, which led her to burst into tears). Jessica also exhibited avoidance of situations that reminded her of the traumatic events (e.g., veered away from talking or thinking about what happened, consumed large quantities of alcohol to cope with trauma-related thoughts). When a friend suggested that she talk about her traumatic experiences, Jessica responded, “I prefer repression.” The friend added, “And self-medication,” referring to her frequent alcohol use. Additionally, she appeared to have negative changes to her thoughts and moods including distorted beliefs about herself and others (e.g., isolated herself from people due to self-blame for what she did under Kilgrave’s control). For example, a neighbor commented that she used sarcasm to distance herself from people and another neighbor stated that Jessica picked apart other people’s happiness because she was all alone (to which Jessica responded, “You are a very perceptive asshole!”). Jessica also told her sister, “I’m life-threatening, Trish. Stay clear of me.” Consistent with this pattern, Jessica tried to push Luke Cage away early in their budding romantic relationship. Finally, Jessica suffered changes in her arousal and reactivity (e.g., irritable mood, angry outbursts, reckless behavior including drinking alcohol to the point of being kicked out of a bar). A lawyer who she worked with described Jessica as “erratic” and “volatile.” When the same lawyer suggested that Kilgrave’s powers might be used for good, Jessica reacted by shattering glass with her fist. Jessica’s response to someone suggesting that she get a massage for stress reduction was, “Massages make me tense,” which is an atypical reaction to massages and may potentially be related to altered reactivity following her traumatic experiences (though this is speculative).

The DSM-5 defines alcohol use disorder as “a problematic pattern of alcohol use leading to significant impairment or distress, as manifested by at least two” of eleven symptoms. Jessica appeared to experience the following symptoms of alcohol use disorder: spending a significant amount of time using and recovering from alcohol (Jessica is shown drinking frequently throughout the day) and cravings to use alcohol (this was especially apparent when Jessica experienced elevated stress levels). It is difficult to assess the presence of some of the other alcohol use disorder symptoms based on the series, but it seemed possible that Jessica also developed some tolerance due to her frequent drinking and may have used alcohol in situations where it was dangerous to do so. Moreover, multiple people commented on her excessive drinking. Trish stated that she had alcoholism, and Kilgrave asked if she thought she drank too much (to which she replied, “It’s the only way I get through my day after how you treated me.”

Treatment Recommendations:
In summary, Jessica appeared to meet full diagnostic criteria for PTSD and alcohol use disorder. Well-established treatments exist for both disorders. Evidence-based treatments for PTSD include therapist-guided processing of traumas (e.g., Cognitive Processing Therapy, Prolonged Exposure) and decreasing unhealthy behavioral patterns without focusing directly on the traumas (e.g., Present-Centered Therapy). With regard to alcohol use disorder, research suggests that multiple types of treatment (e.g., Motivational Enhancement Therapy, which aims to strengthen desire and ability to decrease substance use) are most effective. Finally, Seeking Safety may be an appropriate choice for Jessica, because it is a research-supported treatment specifically designed for individuals struggling with comorbid PTSD and substance use problems. Seeking Safety includes teaching healthy coping strategies and skills to clients, so that they find safety in their relationships, feelings, and thoughts.

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THE GORDON/SAXTON TEST

1. Was the portrayal of mental illness accurate?

The portrayal of mental health problems in Jessica Jones was among the most accurate depictions we’ve seen. It’s rare for works of fiction to clearly identify mental disorders, and PTSD was specifically named as Jessica’s primary mental health problem in the series. Moreover, Jessica exhibited multiple DSM-5 PTSD symptoms, as well as associated distress and impairment, realistically across episodes. Finally, individuals with PTSD are at elevated risk for substance use disorders, and the series realistically displayed Jessica excessively using alcohol in an attempt to reduce the emotional pain she was experiencing.

2. Was the character struggling with mental health issues depicted with compassion?

The series reveals the events leading up to Jessica’s mental health problems in a manner that compels viewers to sympathize with her struggles. The writing and storytelling are superb, and Krysten Ritter is a phenomenal actress. Her portrayal of Jessica reflected a nuanced and complex understanding of PTSD. We believe that the series has the potential to help raise awareness about PTSD to broad audiences, which will hopefully lead to greater empathy for those suffering from it.

Overall rating:
On a scale of be-cool-and-just-watch-one-episode-per-day to RESISTANCE-IS-FUTILE-JUST-SURRENDER-TO-THE-BINGE-WATCH, we rate the depiction of mental health issues in Jessica Jones as RESISTANCE-IS-FUTILE-JUST-SURRENDER-TO-THE-BINGE-WATCH!

For more information on PTSD, please visit the National Center for PTSD website by clicking here.

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