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 “a#$holes” 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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Diagnosing The Dude

PSYCHOLOGICAL REPORT

Client Name: Jeffrey Lebowski, AKA The Dude, His Dudeness, Duder, or El Duderino (if                                         you’re not into the whole brevity thing)
Education: College
Occupation: Currently unemployed
Date of Birth: December 4, 1942
Date of Interview: March 6, 1998
Therapists: Katie Gordon, Brandon Saxton

Presenting Problem
Jeffrey “The Dude” Lebowski was referred for a psychological evaluation by his special lady friend, Maude Lebowski, who told him that we were good people “and thorough.” Once described as “quite possibly the laziest in Los Angeles County, which would place him high in the running for laziest worldwide,” The Dude presented as a 47-year-old man who was dressed casually in a lavender t-shirt, patterned pants, and jelly sandals. Right away, the mental status exam raised clinical concerns, as The Dude did not seem fully oriented to time, person, and place. When asked the date, The Dude responded with, “Is this a…what day is this?” and then asked, “Mind if I do a J?” When asked what his chief complaint was, The Dude explained that his rug had recently been destroyed by people who broke into his house. He appeared very distressed by this, and when asked why it was so bothersome to him, he replied that, “it really tied the room together.”

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History
Gathering a comprehensive history was challenging with The Dude. He reportedly attended college and spent most of his time there “occupying various administration buildings…smoking a lot of Thai stick…breaking into the ROTC…and bowling.” When asked about the type of degree he was pursuing, The Dude stated, “To tell you the truth, I don’t remember most of it.” In response to a question about the kind of work he did, The Dude said, “a little of this, a little of that.” He recalled being a roadie briefly for Metallica on the Speed of Sound tour. He remarked that they were “a bunch of assholes,” and also reported hating “the <expletive> Eagles, man.” Earlier in his life, The Dude engaged in some social activism, reporting that he was one of the Seattle Seven and contributed to the first draft of the Port Huron Statement. Lately, his career had reportedly “slowed down a bit,” such that he spent the majority of his time bowling, driving around, and having an “occasional acid flashback.” The Dude stated that he had friends who he spent time with, and in particular, someone named Walter who played in his bowling league (except on Shabbos). When asked about his marital status, The Dude replied, “Do you see a wedding ring on my finger? Does it look like I’m <expletive> married?”

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Diagnostic Impressions
All assessment information was obtained through observing The Dude in The Big Lebowski. In general, The Dude presented as a laidback, go-with-the-flow kind of guy who seemed generally happy with his life. Thus, we approached our diagnostic examination with an effort to not over-pathologize his eccentricities and stuck to exploring potential areas of distress and impairment. The Dude’s areas of distress included the loss of his rug and tense interactions with his friend, Walter (e.g., when Walter pulled a gun out during a bowling league game). Meanwhile, The Dude exhibited impairment in managing some of his responsibilities (e.g., failing to pay his rent on time, driving unsafely). For example, The Dude attempted to throw a joint out of a closed car window while driving, and it fell in his lap and burned him. He then poured the liquor he was drinking on it and crashed his car.

The possibility of adjustment disorder following the loss of The Dude’s rug was investigated. While The Dude’s emotional and behavioral reactions to the stressor (e.g., going to the real Jeffrey Lebowski’s house to demand a new rug) were a bit out of the norm, they did not cross the threshold into a pattern of clinically significant emotional problems that caused substantial impairment in important areas of functioning. Therefore, adjustment disorder was ultimately ruled out.

The full extent and range of The Dude’s alcohol and other substance use at the time of assessment was not totally clear, but he did mention at least some previous LSD use and tell Maude that he was “adhering to a pretty strict drug regimen to keep my (his) mind limber.” He appeared to, at a minimum, regularly smoke marijuana and drink White Russians. Due to the limited available information, we could not conclusively determine whether he met full criteria for alcohol use disorder. However, he likely met criteria for cannabis use disorder. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)cannabis use disorder is defined as “a problematic pattern of cannabis use leading to significant impairment or distress, as manifested by at least two” of eleven specified symptoms (e.g., tolerance, repeated failed attempts to quit using). He appeared to exhibit the following: 1) a great deal of time is spent in activities necessary to use cannabis 2) recurrent cannabis use in situations in which it is physically hazardous (e.g., driving), and 3) craving, or a strong desire or urge to use cannabis.

Treatment Recommendations
Overall, this is a very complicated case with a lot of ins, a lot of outs, and a lot of what-have-yous. However, the probable diagnosis for The Dude is cannabis use disorder. If The Dude decided to pursue treatment, there are several well-established treatments for substance use disorders that have been tested in rigorous scientific studies. These evidence-based approaches include strategies focused on enhancing motivation for change (motivational interviewingmotivational enhancement therapy), identifying and changing thoughts and behaviors that contribute to the substance use problem (motivational enhancement therapy plus cognitive-behavioral therapy), and participation in a behavioral program that reinforces drug abstinence (prize-based contingency management).

Status at Follow-Up 
The Dude abides.

THE GORDON/SAXTON TEST

Was the portrayal of mental illness accurate?
The Dude’s primary purpose as a fictional character is comedic in nature. Nonetheless, he does exhibit some symptoms that are realistically consistent with cannabis use disorder (as outlined above). Remarkably, his character was based on a real person who has striking similarities to the fictional Dude. Check out this video about the real Dude (Jeff Dowd), who views his fictional counterpart affectionately as a holy fool, which he defines as “one who subverts conformity in order to point to the truth in a funny way.”

Was the character struggling with mental health issues depicted with compassion?
Even though The Dude is fairly irresponsible during the time period depicted in the film, people seem to really like him, want to emulate aspects of his approach to life (e.g., some view it as consistent with Zen philosophy), and feel sympathy for the loss of his rug. Therefore, it seems reasonable to conclude that he is portrayed with some compassion…but, that’s just like our opinion, man.

Overall rating: On a scale of very Dude to very un-Dude, we rate this portrayal as calmer than you are!

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Silent Bob’s Psyche

PSYCHOLOGICAL REPORT

Client Name: Silent Bob
Date and Location of Birth: 1970s-ish in New Jersey
Date of Initial Interview: January 19, 2006
Date of Report: July 21, 2006
Therapists: Katie Gordon, Brandon Saxton

Presenting Problem
Silent Bob presented as a man in his early 30s who was dressed in a backwards hat, long coat, and jeans. After we greeted him in the waiting room, he used charade-like behavior to ask if we would hold the session outside so that he could smoke cigarettes. After going to an outside area, he leaned against a wall, and continued to communicate mostly through emphatic facial expressions and gestures rather than speaking.

A review of Silent Bob’s paperwork indicated that he was court-ordered to treatment following charges of possession of marijuana with intent to sell. The police report stated that he and his friend, Jay, were driving around with a deployed airbag when a police officer pulled them over for “suspicion of mischief.” The police officer then searched their car and found two pounds of “Jamaican Landswolf” marijuana. The prosecutor wanted Jay and Silent Bob to be sentenced to prison for ten years, but the judge ordered them to complete drug rehabilitation instead.

Educational/Employment History
Silent Bob completed a minimum of eighth grade (when he won the science fair) and likely continued beyond that. However, details could not be confidently discerned from Silent Bob’s gestures. After completing school, he became a self-employed drug dealer with his best friend, Jay. He and Jay particularly enjoyed selling marijuana in front of a Quick Stop convenience store in New Jersey. Another source of income for Silent Bob was from a movie (Bluntman and Chronic) that was developed from a comic book starring a character based on him.

Psychosocial History
Little is known about Silent Bob’s family history and not much could be gleaned from his nonverbal behavior on this topic either. There was one mention of his mother, in that he won that eighth grade science fair by turning one of her personal belongings into a CD player through the use of chicken wire. For this accomplishment, his friend Jay referred to him as an “electrical genius” and “better than MacGyver.” He also reportedly had a cousin named Olaf from Moscow, Russia who was a metal singer.

In terms of significant romantic relationships, Silent Bob was in a relationship with a woman named Amy approximately ten years prior to the initial interview. In a rare moment of speech, he described them as “inseparable” and “big time in love.” Due to feelings of insecurity about her romantic past, he ended their relationship and deeply regretted it, saying that he “spent every day since then Chasing Amy…so to speak.”

With regard to friendships, Silent Bob spent most of his time with his best friend, Jay, ever since they met as young babies in strollers outside of the Quick Stop. Together, they spent the vast majority of their time loitering, smoking and selling marijuana, and beating up people who were critical of Bluntman and Chronic on the internet. True to his name, Bob was often silent while Jay regaled him and others with crass, colorful stories and commentary. They also enjoyed listening to music together and dancing while loitering. In fact, during one of the rare times when Silent Bob spoke, he revealed that he “always wanted to be a dancer in Vegas.” It should be noted that, as occasions arose to help others, Jay and Silent Bob often stepped up to the challenge. For example, they once helped their friends T.S. and Brodie reunite with their ex-girlfriends and, another time, they liberated animals from a testing facility. Remarkably, they also played important roles in preventing two fallen angels (Bartleby and Loki) from ending all of existence.

Diagnostic Impressions
All assessment information was obtained through behavioral observations and record review (i.e., watching, reading, and listening to ALL the Kevin Smith movies, books, and podcasts). First, due to the nature of the court-ordered referral, Silent Bob was evaluated for disorders related to his marijuana use. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), cannabis use disorder is defined as “a problematic pattern of cannabis use leading to significant impairment or distress, as manifested by at least two” of eleven specified symptoms (e.g., tolerance, withdrawal, repeated use in dangerous situations such as driving, repeated failed attempts to cease marijuana use). Due to the limited communication from Silent Bob during the assessment, we could not conclusively determine whether he met full criteria for this disorder. However, we speculated that he was likely to have met criteria for cannabis use disorder as evidenced by the following symptoms: 1) substantial time devoted to obtaining and using cannabis and 2) the presence of intense cravings to use cannabis. Moreover, he appeared to be experiencing associated impairment in light of his legal troubles.

Secondly, Silent Bob also appeared to meet criteria for a second disorder: selective mutism. He exhibited all of the DSM-5 criteria for selective mutism: 1) repeated failure to speak in social situations where one is expected to speak, despite speaking in other situations, 2) the disturbance interferes with social communication, 3) the duration is at least one month, 4) the failure to speak is not attributable to lack of knowledge of spoken language.

Treatment Recommendations
In summary, probable diagnoses for Silent Bob include cannabis use disorder and selective mutism. Currently, there are several well-established treatments for substance use disorders that have been tested in rigorous scientific studies. These evidence-based approaches include strategies focused on enhancing motivation for change (motivational interviewing, motivational enhancement therapy), identifying and changing thoughts and behaviors that contribute to the substance use problem (motivational enhancement therapy plus cognitive-behavioral therapy), and participation in a behavioral program that reinforces drug abstinence (prize-based contingency management).

With regard to Silent Bob’s selective mutism, existing scientific evidence points to cognitive-behavioral approaches as effective. These approaches teach individuals with the disorder skills for adaptively coping with and reducing the obstacles to their verbal communication, while behaviorally reinforcing them for communicating through spoken language.

Status at Follow-Up (Clerks II)
At a follow-up session six months and two days later, Silent Bob denied the presence of any cannabis use disorder symptoms. Through a series of questions that Silent Bob responded to with head nods, head shakes, gestures, and occasionally drawing pictures, we determined that he had maintained sobriety since our initial meeting. He attributed his marijuana abstinence to his enrollment in a six-month rehabilitation program that utilized the 12 Steps of Narcotics Anonymous. While Silent Bob should be commended for his dramatic behavioral change, there were several risk factors for relapse that were identified. First, his beloved Quick Stop convenience store had burned down. He was reportedly coping with this stressor by loitering in front of a fast-food restaurant (Mooby’s) instead. Secondly, though Jay was also sober, they both continued to sell marijuana. When asked how he would resist smoking marijuana while selling it, he pulled a bible out of his coat. Silent Bob had been raised Catholic and reconnected with Christianity during rehabilitation, which led him to feel that his spiritual connection would prevent a relapse. Nonetheless, it was strongly recommended that Silent Bob explore other occupations in order to reduce his chances of relapsing.

THE GORDON/SAXTON TEST

1. Was the portrayal of mental illness accurate?

Silent Bob is a comedic character that Kevin Smith created mainly so that the character, Jay, had someone on the receiving end of all of his funny behavior. Still, he does exhibit symptoms that are realistically consistent with cannabis use disorder, as outlined above. With regard to selective mutism, Silent Bob exhibits many of the actual symptoms of the disorder. However, it is worth noting that the disorder is extremely rare in adults and tends to occur in children. Moreover, it is likely that Silent Bob would speak more frequently to Jay in the context of their close friendship. In children with selective mutism, they often speak with their family members and sometimes close friends, but are silent in other settings (e.g., in school, with strangers).

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

As mentioned above, Kevin Smith was not specifically aiming to have Silent Bob represent a person suffering from mental health issues. However, Silent Bob is certainly a likable character. Furthermore, it is very clear from reading Kevin Smith’s books and listening to his podcasts that he has great compassion for his friends who have struggled with substance use and other mental health issues. He is openly supportive and helpful to his friends in real life, and in this way, he helps to reduce stigma surrounding these mental health issues.

Overall rating: On a scale of snoogans to snootchie bootchies, we rate this portrayal as snootch to the nootch!

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