Crisis intervention strategies and best practices

Bob

Crisis Intervention

What about Bob?:

A psychological overview

"I have...problems" the patient Bob Wylie whines, in his first session with his psychiatrist in the film What about Bob? The film details the near-traumatizing experience of the psychiatrist in treating Bob over the course of the film. Bob is a white, middle-class, middle-aged divorced man who has multiple phobias and is also highly manipulative in terms of how he interacts with the psychiatrist's family. Bob's lack of social connections in terms of friends and family become particularly manifest in the film as he strives to be 'adopted' by his therapist, whom he follows (stalks) when the therapist is on vacation. Bob is afraid of most social interactions (yet is pathetically needy), is germ-o-phobic (he is afraid to touch anything directly) and is a hypochondriac (he fears everything from having a heart attack to having his organs explode unexpectedly).

The crisis Bob experiences during the film is immediately touched off by his divorce, which he seems unable to explain in a coherent fashion (he blames it on his difference of opinion with his wife on the subject of Neil Diamond). However, clearly his crisis has long-standing, deeper roots that a single relationship. In a more conventional therapeutic setting (in other words, when being seen by a more competent therapist than his on-screen psychologist) Bob would be diagnosed as having a personality disorder, rather than a mood disorder such as depression.

According to the DSM, a personality disorder is an appropriate diagnosis when a patient exhibits "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture. This pattern is manifested in two (or more) of the following areas," namely of cognition or "ways of perceiving and interpreting self, other people, and events;" affectivity, "the range, intensity, lability, and appropriateness of emotional response;" "interpersonal functioning;" and "impulse control" (Personality disorder, 2011, Behave Net). Bob clearly displays deficits in all of these areas, as is manifested by the fact that he 'follows' his therapist on vacation. Bob's hysterical fears of abandonment, sickness, and contamination deviate markedly from the expectations of a culture that expects him to be able to tolerate separation from loved ones for short periods of time and to eventually 'pick up the pieces' emotionally, after a divorce. Bob's emotions regarding abandonment are overly intense, as manifested by the fact that he follows his therapist on vacation. And his actions regarding germs and potentially life-threatening illnesses are also extreme and unrealistic. Everyone fears sickness to some degree, but allowing such fears to limit or to control social interactions are not 'normal.'

The fact that Bob's obsessions and feelings about others interfere with normal interpersonal functioning are manifest in the fact that he has no friends and his troubles holding down a job or staying in a marriage. Even his therapist is frustrated by his patient's neediness. Bob is also unable to show any appropriate methods of impulse control at all. He follows his therapist as if the need to depend upon the man is an itch he cannot help but scratch, just as he fakes various illnesses, both as a means of gaining attention but also because he genuinely believes that if he does not have medical attention all of the time, he will die.

Regarding Bob's formal diagnosis, the film is unclear. His therapist is so desperate to be free of Bob, he checks Bob into a psychiatric unit. However, Bob is quickly released, and his humor ("Roses are red, violets are blue...I'm a schizophrenic, and so am I") cause the staff at the hospital to think Bob has no problems at all. Although Bob's thinking may be maladapted and maladjusted, he is not disassociated from reality like a schizophrenic who hears voices.

Bob's hypochondria and obsessions with cleanliness clearly show signs of obsessive-compulsive behaviors. However, he lacks the perfectionism and obsession with numbers that is characteristic of this particular illness. Also, obsessive-compulsive personalities tend to be excessively devoted to work, miserly, and perfectionist in nature, and show little need for the help of others (OCD, 2011, Behave Net). In contrast, Bob is very open about his near-pathetic neediness (he is so needy that even the therapist's children befriend him out of sympathy). Bob shows a majority of clinical symptoms associated with Borderline Personality Disorder, a disorder that is marked by a near-hysterical fear of abandonment. Bob's worries about his health seem to be a thinly-masked way of having people pay attention to him. In fact, the 'cross-pollination' with other disorders is common in BPD patients: "The proper management of patients with BPD also requires taking into account the totality of their personality. Clinicians will rarely, if ever, encounter a borderline patient in whom BPD is the only diagnosable 'category' (a la DSM) of personality disorder" (Stone 2006).

According to the DSM criteria for Borderline Personality Disorder (BPD), Bob does show "frantic efforts to avoid real or imagined abandonment," including by his therapist (Borderline Personality Disorder, 2011, Behave Net). He also shows "a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation," as manifested in his relationship with his wife, who was abandoned because they had different musical tastes, and his intense idealization of his therapist, which extends beyond the usual 'transference' or sublimated sexualization of the relationship (Borderline Personality Disorder, 2011, Behave Net). Bob's lack of self-esteem is evidence of a clear "identity disturbance," or a "markedly and persistently unstable self-image or sense of self" and he shows impulsivity in his actions when following his therapist on vacation and faking illnesses. While he does not abuse drugs, engage in binge-eating or cutting, or show inappropriate levels of anger (Bob tends to be passive rather than rage-filled) his unstable moods, chronic feelings of emptiness, paranoia and suicidal gestures also suggest BPD, according to the diagnostic criteria.

Cognitive Behavioral Therapy (CBT) is one of the most effective treatments for BPD to date. Traditionally, BPD is considered one of the most stressful illnesses for therapists to treat, and even though the character in What About Bob is shown to be a narcissistic, bad therapist, the frustrations of dealing with a chronically needy patient should not be dismissed as a mere source of comedy. A tentative crisis intervention plan for Bob would include a course of CBT, with a specific duration of sessions to ensure that Bob did not try to make the therapy continue indefinitely, as an expression of his neediness.