Diagnosis for Will of Good Will Hunting Linn Thomas Gubala Walden University November 14, 2014 COUN 6781 Psychopathology from a Clinical Perspective Abstract Due to continuous abuse in a foster home as he was growing up, Will has developed Avoidant personality disorder, with post traumatic stress disorder, and possibly mood disorder of depressive symptoms. He also has an inferiority complex. He has a lot of knowledge of facts, but has lack of real life experience. Another possibility is that he has oppositional defiant disorder, because of his anger and persistent irritability, argumentativeness, defiant behavior, and vindictiveness. His mood disorder showed up as he performed defensive acts when there was nothing to worry about; such as trivial events. However, he was not prescribed any mood altering drugs and turned out fine through simple counseling, albeit an unconventional Hollywood portrayal of it. He had anger and violence brought on by memories of his past abuse, and being treated unfairly. Even if he was not forced to react in this way, he did so anyway. Likewise, his inferiority complex has arisen out of childhood abuse, and continues to affect his life today. Since his foster family did not care for him, they neglected to treat his psychological problems, causing them to progress and get worse. Such a person should get immediate psychological treatment by a psychologist to prevent it. Diagnosis for Will of Good Will Hunting The Case Study In the theoretical case study based upon the motion picture Good Will Hunting (Weinstein, et al., 1997), Will was shown as a 20-year-old white male, of Irish-American heritage, from the south of Boston, locally known as a “Southie.” He turned 21 and was given an old used car, a Chevrolet Nova, for his birthday by his closest friends. He is a janitor at the Massachusetts Institute of Technology, and lives close to Harvard. It turns out that he is a mathematical genius, as he was able to solve a challenge problem up on the board in the hall. None of the other students were able to solve the problem, but for Will it seemed effortless. It is a wonder that he has had so much time to read books, and gain knowledge. Doubtless, this is from all his time spent alone. Building up barriers and preferring to be alone is a sign he might have antisocial personality disorder. However, he does have some close childhood friends that he associates with, he goes out to the bars, and is not afraid of altercations and fights. He fights with adversaries who have bullied him, and rebels against authority figures. Here he presents as a new client for diagnosis. In the end of the movie, he was seen leaving Boston, where he has spent his whole life, and taking a chance on the relationship with his new girlfriend by moving out to be with her in California (Weinstein, et al., 1997). Now he is evidently coming in for follow-up therapy treatment with a new therapist, the author. Background Information Some of the ways Will was treated poorly in foster care were physical, emotional, and verbal abuse. He is also an orphan who has been shuffled around to various foster homes. At one in particular, he suffered at the sadistic hands of his alcoholic step-father, who would beat him up physically using various objects such as a wrench. He was not shown love or nurturing in the homes, and now does not trust to get near people and form relationships. He was often ridiculed, until he believed he was worthless, and his best was never good enough. He also had cigarettes put out on his skin, and beaten repetitively, and even has stab wounds. Because of this distrust for adult male and authority figures, he is humble, and does not seek to advance into anything beyond working class (although it is noble). It has held him back, and he is unable to thrive. In a conversation Will had with Skylar, he told her he came from a large Irish-Catholic family, and therefore has 12 older brothers; Marky, Ricky, Danny, Terry, Mikey, Davey, Timmy, Tommy, Joey, Robby, Johnny, and Brian (Weinstein, et al., 1997). This of course was only a fantasy of his, since he came from foster care, and undoubtedly spent much time memorizing this list, as evidenced by his ability to rapidly repeat it again. However, he was ashamed to show Skylar where he lived, and reluctant to finally have her meet any of the brothers or family, because they did not really exist. He wanted them to exist so badly that he made them up. Past Counseling Sessions for Will Will had initially been court-ordered to attend counseling sessions. The mathematics professor at MIT who discovered his genius, Gerald Lambeau, found out he was in trouble and worked out a deal with the judge who would allow for his parole if certain conditions were met. The judge knew that Will had managed to get out of trouble on technicalities on many occasions in the past, and was ready to get tough with him. However, Mr. Lambeau was able to convince the judge that Will had much potential, if he could just work with Will on his problems, and get better. Mr. Lambeau earlier had been able to win a prestigious field medal, and he saw the same abilities coming natural to Will that had taken him years to achieve. At one point he taunted Mr. Lambeau by crumpling his paper containing complex mathematical formulas and lighting them on fire, exclaiming that they were easy for him (Will) but not for Lambeau. As Lambeau scrambles to put out the fire, he lamented that he wished he had never met Will (Weinstein, et al, 1997). The first two therapists were miserable failures with Will. Although they were learned, and used conventional methods and guidelines, Will rebelled against their seeming authority, because of his stance against authority figures who had abused him in the past. Because the first one seemed a bit too interested and friendly with him, Will accused him of being gay. Social class dynamics also came into play, since he acted overly pretentious. Will could sense he was trying too hard, and was not being genuine. It became too easy for Will to project his anger out at him. This doctor finally could not take anymore taunting from Will and stormed out of the room complaining. Then with the hypnosis-therapist, Will malingered and pretended to be under hypnosis, and started poking fun at the whole process by talking about what he felt the therapist wanted to hear; about being molested, then singing Afternoon Delight originally released by Starland Vocal Band (Danoff, 1995). This action is much like the malingering or feigning wellness by Malcolm Rivers portrayed in the film Identity (Konrad, Capp, & Besser, 2003), because then the main character in that movie also turned out to have the problem that the therapist felt he had (Dissociative Identity, or multiple personality disorder), but made the attending psychologist appear foolish at that time for even suggesting that he did. Finally, Lambeau selects Sean McGuire, an old acquaintance and college roommate of his (for which a bitter rivalry still secretly exists) to help rehabilitate Will. Sean was relegated to teaching psychology and counseling at a community college. His making light of ethical standards and his unconventional loose practices while counseling Will Hunting have been widely criticized. Sean used self-disclosure to build rapport, and to gain Will’s trust. Transference was used so Will would open up, and to see Sean as the kindly father figure he never knew. He began to re-parent Will. He had to bring the pain to the surface and deal with it. He showed Will empathy, which Will could never reflect to others, because he had not received it himself. The second session, they sat and briefly talked on a park bench in Boston Public Gardens where young families traditionally bring their children to ride on boats with swan decorations in the lake there (Weinstein, et. al., 1997). He told Will that he might have plenty of knowledge from books, but lacked vital life experience. Sean’s treatment of Will seems to make the most sense with attachment theory of Bowlby (1999), because when a baby or child is growing up it learns to depend upon its caregiver to respond with empathy to its needs according to its cry. This affective attunement lets the child know the caregiver is aware of his or her emotions, and connects by responding in a loving way. In the foster care system, a child never gets to be with one parent long enough to develop a bond before being whisked away to the next one. They end up not trusting anyone, and close up into a reclusive shell. Sean used unconventional treatment, such as self-disclosure, so Will would see his genuine human nature, and that he is not just another typical adult out to hurt him. But these unconventional approaches worked and they would not have achieved results without them. This is why other therapists had failed before when attempting to treat Will. Mental Health Diagnosis of Will Hunting It has been speculated that Will Hunting has attachment disorder, according to attachment theory (Bowlby, 1999). Berke (n.d.) opined that Will had oppositional defiant disorder based on her application of various developmental theories, most notably Erikson’s psychosocial development theory, but this mainly only serves to show where Will’s development was stalled by his abusers. Her paper also contained numerous flaws. Nevertheless, oppositional defiant disorder will be examined here also as a possibility for diagnosis to aid in his treatment from this point forward. The Criteria for Reactive Attachment Disorder Unfortunately, the classification for reactive attachment disorder [RAD] (313.89 in DSM 5; American Psychiatric Association [APA], 2013, pp. 265-268) is not the same attachment disorder based upon the attachment theory by Bowlby (1999) which so well explained the situation and diagnosis of Will. It is, however, in the DSM 5 chapter concerning trauma and stressor related disorders, which also included its partner; disinhibited social engagement disorder (although Will definitely is not describable as disinhibited socially and in relationships, except with fighting and conflict); and PTSD, which although formulated for veterans from wars, is certainly applicable to trauma from abuse seen in children, and applicable to disorder stemming from Will’s abuse. Social neglect, or the failure of needs being met by caregiver adults, is a requirement for reactive attachment disorder and disinhibited social engagement disorder (APA, 2013). The difference is that in reactive attachment disorder, the patient internalizes problems, and experiences depression; and with disinhibited social engagement disorder, he or she externalizes problems by acting out without inhibition (APA, 2013). By these definitions, both disorders could apply to Will, but the latter to a lesser degree. Still, reactive attachment disorder is focused on children exhibiting disturbance by the age of 5 years old; caution is to be used when diagnosing children over the age of 5, and it is rarely seen in a clinical setting (APA, 2013). In contrast, Will Hunting is now over 21 years of age and considered an adult. Therefore, this is but one of the frustrating scenarios where the DSM does not accurately help in depicting a clear-cut picture for clinicians to use in an individual’s diagnosis. Meeting the Criteria for Avoidant Personality Disorder In the DSM 5, the Axis II personality disorders have been eliminated, mostly because clinicians were not attending to all five axes, but instead focusing on Axis I issues requiring clinical attention (Paris, 2013). Personality disorders are sometimes seen as just inherent differences in character of an individual. Personality disorders result in significant distress or impairment in social, occupational, and other areas of life (APA, 2013). Thankfully they can often be successfully treated by psychotherapy, counseling, and various intervention techniques (such as cognitive-behavioral group therapy; Hope, Herbert, and White, 1995), rather than resorting to mood altering drugs. People with avoidant personality disorder exhibit a pattern of social inhibition, sensitivity to criticism, and feeling inadequate, beginning at adulthood (APA, 2013). Will avoids occupational and interpersonal contact where he could be criticized, disapproved of, or rejected. He is resistant to get involved with people like Skylar unless he can be certain that she will totally accept and like him. He shows restraint in intimacy; fearing shaming, and ridiculing as a result. Will is also constantly thinking about what to do if he receives criticism and rejection socially, and the response or come-back line he will give them. This was evident by the scene in which he shows up the rival at the Harvard bar (Weinstein, et al., 1997). His feelings of inadequacy hold him back in interpersonal situations, and he views himself as socially inept, unappealing, or inferior. This was evidenced by his humble attitude with approach to life decisions. Finally, he is reluctant to take risks and take up new activities that may end up embarrassing him. The Avoidant Personality disorder that Will exhibits limits his positive interaction with people that would enrich, fulfill, and enhance his life the most, such as venturing for new job opportunity interviews, relationship intimacy, and viable friendships with more people. Meeting the Criteria for Oppositional Defiant Disorder Oppositional defiant disorder [ODD] is in the Disruptive, Impulse-Control, and Conduct Disorder chapter of the DSM 5 (APA, 2013). Requirements include often having angry or irritable mood (APA, 2013). Will loses his temper, is touchy, and annoyed by situations he feels are not right, such as the NSA focus on code-breaking when there is more important issues to care about. He is often angry and resentful. He has been spiteful and vindictive at least twice in 6 months. ODD has its onset in childhood or adolescence and comes with antisocial behavior, and attention deficit hyperactivity disorder (ADHD), academic underachievement and delinquency; developing into prison time as adults (Brown et al., 2008). However, Will does not persistently demonstrate the general disregard for, and violation of, rights of other people required for antisocial personality disorder (APA, 2013). He does not seem to suffer from ADHD or academic underachievement if he wished to continue his education. However, he has suffered delinquency, and faced possible jail time. Excluding Other Diagnoses Will does not appear to have depression alone, as he does not exhibit enough symptoms. He mainly has the lower self-esteem. Yet he does have depressive symptoms with his main diagnosis. He does not have hallucinations, such as in schizophrenia. He knows he does not really have 12 brothers. He just used that as a front. He does not abuse drugs, nor have a history of drug abuse. He only drinks socially and in moderation. Risk and Resilience Factors Will was concerned that he would not be able to cope with the move to California because he could be rejected by his new girlfriend, and not be able to regain employment and housing in the new state. Furthermore, he would be detached from the only friends he felt ever accepted him, the peers from his neighborhood who had not bullied him, and that he would not have the ability to gain new friends that were as close. However, Will has intellectual abilities that would afford him lucrative and gainful employment, once he accepts that his gifts are only to be wasted if he does not take them seriously. In fact, in other cases, clients would get discouraged because they do not have these strengths. So perhaps Will is an atypical example. He rejects the establishment, because of his distrust of governmental and big corporate power he sees as authority. He feels their aim is to hurt people, rather than help them, which means he feels mathematical ability is no more useful than a challenging game or amusing puzzle. However, recently he has been prompted by his closest friend Chuckie, to step out and make something of himself, based upon Chuckie’s advice that they talked about (Weinstein, et al., 1997). Will and Chuckie worked together daily at a construction job. Chuckie told Will that he owed it to everyone that cared about and loved him the most to step outside his comfort zone and be somebody important commensurate to his skills. Chuckie stated that he himself would still be there working at the same company, but that his biggest wish was that Will would take off suddenly one day and follow his dream (Weinstein, et al., 1997). Paris (2013) stated that part of the difficulty when diagnosing PTSD is that nearly everyone has experienced trauma and adversity in their lives. He goes on to state that the main problem with PTSD and many other disorders is the boundary with normality. Here Will had led a fairly normal life, except when he had brushes with the law due to his violent tendencies. He finally assaulted someone who was a former bully of his (Weinstein, et al., 1997). Because of this, he had been ordered by the judge to seek counseling to get to the root of his problems, to avoid jail time. Although he often resisted, sometimes going through the session in silence, he made it through and had breakthroughs. He did not continue at the prestigious job that he was offered, deciding instead to take a chance on Skylar. Likewise, Sean benefited from the exchange and encouragement from Will by deciding to move on with life after his wife’s death. Will does not seem to have depression, although his situation has sometimes caused him depressive symptoms. He showed initiative from solving the mathematical equation, to finally making the move to California. Therefore, his prognosis for improvement is favorable. Psychosocial and Family Issues Will was ashamed to show new acquaintances where he lived because of the dynamic class distinctions around Boston. Apparently he would have been proud to have a large happy natural family of origin, and it was something he had lamented upon during many occasions. He did not want to seem as though he came from a dysfunctional family or had been shuffled around. Will assumed his new girlfriend would reject him, as many foster parents had done, when she found out that he was not from a large loving family, but an orphan from foster care who suffered physical, verbal, and emotional abuse. Will and his friends speak rather abusively to each other at times, and the argumentative nature urging them to fight others is extremely adversarial and not nurturing. Moreover, he pushes others away, erecting a wall to intimacy. He is afraid to take risks with relationships that he will be betrayed again, as he was with his former caregivers, growing up when development of empathy and trust was at a crucial stage. However, the decision to take a risk on a love relationship led his move to California, where he is now seeking employment. Career and Vocation Will argued that there is no shame in being a janitor, or a construction worker, and that one can have pride in one’s work as a brick layer, and stay in the town one is in until the day that he dies. Robin Williams’ character agreed with this and he offered the example of his father, who was a bricklayer and worked very hard to provide for his family; an honest day’s work for an honest day’s pay. As the issues were resolved, the important lesson was learned that if one is entrusted with a gift, such as a penchant for mathematical genius, one is more obligated to use it to the fullest, to help humanity, and not waste their gift. Unfortunately, Williams appears to have not taken away enough from his film examples to help him in his real personal life, but he probably suffered instead from major depression, and unlike in the Good Will Hunting case, needed psychopharmacological options to alleviate his debilitating mood disorders. Legal and Ethical Issues Breaching the relationship between therapist and client is potentially harmful, although it did not turn out harmful in the sessions with Sean McGuire. The American Counseling Association [ACA] Code of Ethics (2014) discusses that counselors must avoid harm to their clients in section A.4, and avoid roles unrelated to counseling as dual relationships are under section A.5. Also, the American Psychological Association [APA] in the American Psychological Association ethical principles of psychologists and code of conduct (2002) discussed the importance of this in Section 10.06-10.08; sexual relationships, and 3.05; multiple relationships. An example of what harm can happen in an inappropriate romantic or sexual relationship is evident in the motion picture The Color of Night (Vajna, Feitshans, Zozzora, Matalon, & Willis, 1999). But there was no chance of that happening because both Will and Sean are not at all gay. Their relationship was more like a father-son relationship. Still there is always the potential for iatrogenic harm, such as dual relationships, which they quickly made light of and dismissed in Good Will Hunting (Weinstein, et al., 1997). Professional boundaries seem to not exist in treatment in this movie. Sean’s interaction with Will seems public. Sean openly discusses Will’s case with Gerald. Will actually walked in while they are arguing about him, hearing the tail end of the discussion (Weinstein, et al., 1997). So, there is virtually no confidentiality. Also, it probably did not help when Sean got angry, charged at, and choked Will to the wall (Weinstein, et al., 1997). He could have had a flashback to his former abuse, as PTSD sufferers commonly do. But the two characters are a lot alike, Sean is simply older. They both see themselves in the painting Sean had hanging in his office, which Will criticized. And they are both originally from South Boston, a place with a low socioeconomic class of struggling people. Continuation of Assessment Continuing assessment is necessary to ensure that Will does not regress and lose his progress that has been made up until this point working with Dr. McGuire. Although Will’s speech in the motion picture was riddled with expletives (Weinstein, et al., 1997), others in his life responded in similar fashion, including his therapist. It is inadvisable, though, and unprofessional to respond with cuss and swear words. In the movie, the breakthrough, which usually could take weeks or months, was expertly condensed into one scene, where Sean states repeatedly (ten times) that it is not Will’s fault. This seems to have worked enough for the time being, even spurring him to take on the risks by accepting the job, but then following Skylar to California. But it may not be enough to conquer subsequent feelings resurfacing of inadequacy, inferiority, self-doubt, or worthlessness. Follow-up Recommendations for Treatment of Will Although this is not a treatment plan for the client, Will Hunting is best helped through psychotherapy, and not psychopharmacology. Sean did not prescribe any drugs to Will, and neither did any other doctors. Drugs are not likely to be needed according to what has been seen so far, because his depression has been minimal compared to his roadblocks and resistance for advancing toward his potential. Routine maintenance of his progress will be assessed from time to time, until termination is deemed appropriate. According to the APA (2002), the attending psychologist may terminate when the client no longer is in need of services, is not likely to benefit any more from continued services, or may be harmed by continuation. A genuine person-centered approach, such as Rogers portrayed, would be advisable for Will, because it shows empathy and unconditional positive regard (Kirschenbaum, & Jourdan, 2005) and because he has revolted, and likely will not respond well to pretentiousness and sensed authority. For example, the author presently drives a late-model BMW because one of his best friends needed to sell one. If Will were to view the therapist arriving or departing with such a car seen as an upper-class vehicle, he would be liable to revolt (Felski, 2000). Conclusion According to attachment theory (Bowlby, 1999), when Will was a baby he did not receive enough comfort and empathy of his needs and feelings reflected from an adult caregiver, and consequently never learned to reciprocate and accept comfort from an adult of an authority figure. Furthermore, as an adult now himself, he cannot take comfort in a secure relationship with his girlfriend Skylar. However, since he chose to take the step of taking a chance and moving out to California after receiving unconventional counseling from Sean McGuire, he is becoming more dependent upon her, and removing the walls inhibiting intimacy. He is no longer in a shell, relying on himself, but opening up to people. This kind of improvement should continue throughout subsequent counseling, but radical methods are no longer needed. Care should be taken to not breach ethics laid out in the Code of Ethics for the APA (2002), or the ACA (2014). Skylar was deeply hurt in the motion picture (Weinstein, et al., 1997) because Will could not manage to tell her he loved her in return. At first he was actually afraid to call her, in one instance holding the phone briefly in silence before hanging up. Although he overcame that initial fear of calling and talking to her on the phone, he may still not have resolve all of his intimacy issues with her, and follow-up couple’s therapy might provide a needed boost to their relationship skills. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. American Psychological Association. (2002). American Psychological Association ethical principles of psychologists and code of conduct. American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author. Retrieved from http://www.counseling.org/knowledge-center/ethics#sthash.gEz9IZ5b.dpuf Berke, J. (n.d.). Good Will Hunting; A Theoretical Analysis and Application of Personaility Theories. Retrieved from https://www.academia.edu/5022849/Good_Will_Hunting_ ATheoretical_Analysisand_Applicationof_Personaility_ Theories Bowlby, J. (1999). [1982]. Attachment. 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