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This series is in the vein of several other series or articles where authors discuss the psychological profile or diagnosis of fictional characters, but taken a step further to talk about how I would actually go about psychotherapy with this character. My goal with this series is to show the variety of options in the world of psychotherapy – there really is something for everyone! Also to show some of the thinking that goes into psychological treatment – the theory, the research, and the adaptations that skillful therapists make to complex cases.

As always my disclaimer applies here, and be warned of spoilers ahead.

Case Conceptualization

As the father of two girls, I am probably one of the world’s foremost experts on the characters from Frozen. Also Paw Patrol. Also Doc McStuffins.

I know that feel, bro.



If you haven’t seen the movie, Elsa is the rare Disney princess who ends up becoming a Disney queen. She has magical ice powers that she intermittently loses control of these powers, especially when she is afraid. She spends the majority of the movie unsuccessfully trying to control her powers by trying to squash down her fear. By the end of the movie she learns that the true key to controlling her powers isn’t by decreasing her fear but by increasing her love, and everyone is happy and songs are sung. You know, Disney stuff.

I generally bypass talking about diagnoses in these articles, but Elsa is actually a pretty interesting diagnostic case. As they say in the movie, “Fear [is] the enemy”, and you could make a pretty convincing case for just about any anxiety-related disorder diagnosis. She’s got enough free-floating anxiety to talk about general anxiety disorder. She stays in her room enough that there’s an agoraphobic aspect to her. We see a pretty convincing panic attack.

What, you don’t shoot ice out of your chest when you have a panic attack?

Still, I think the most interesting diagnostic considerations for Elsa are PTSD and OCD. The PTSD would probably stem from the intro scene where Elsa accidentally tags her sister, Anna, in the head with an ice missile.

This may be an example of “Moral Injury”, where an individual commits an act that transgresses against their own deeply held values and beliefs. This would be the pacifist who kills someone else in self-defense.

Or a panda.

At first I thought this wouldn’t be a great example of moral injury, but it turns out that it’s a pretty murky concept. It’s also not clear how much overlap there is between moral injury and PTSD. Regardless, Elsa shows several classic signs of PTSD – avoidant behaviors, negative thoughts and beliefs. We even see Elsa have a momentary flashback in the movie.

I couldn’t find the clip, here’s a capybara.

So PTSD is a maybe. And even though I’ve said you don’t have it, OCD is also definitely on the table. Beyond specific symptoms, one of the hallmarks of OCD is an ineffective attempt to control or prevent bad thoughts or feelings, which is pretty much wrapped up in Elsa’s mission statement of “conceal, don’t feel.” We don’t see much in the way of compulsive behaviors, though, beyond wearing gloves.

There’s enough missing from the PTSD and OCD pictures that I would tend to stick with the Panic Disorder with Agoraphobia diagnosis to start off with, but as we’ll see, that might not even matter.

Treatment Plan

My preferred treatments for PTSD, OCD and Panic Disorder are, respectively, Prolonged Exposure, Exposure and Response Prevention, and Interoceptive Exposure. What do you think those three treatments have in common?

Not this kind of exposure.

Exposure therapy is explained in the name: you expose the individual to whatever scares them. There is usually a gradual ramp-up, where you break down the scary thing into its component parts and then practice the exposure on each part. There are a few theories about how exposure therapy works, including habituation – or you just get used to it, and belief disconfirmation – or learning that the fear that you’ve built up in your head just isn’t realistic. Theory aside, the focus is on pushing through the fear, and learning that it’s ok to be afraid.

Except for Elsa…

Not OK.

Elsa flips the script on anxiety treatment, because for her, fear is the problem. So fine, we can’t turn the fear nozzle down, that just means we have to turn the love nozzle up.

Note: Don’t google search for love nozzle.

The end of the movie establishes that “Love can thaw a frozen heart,” and therefore love is the key to undoing Elsa’s magic. I’m not going to argue the Disney logic of love as the counter to fear, but I am going to say that we’re going to have to do some ACT.

ACT for Elsa

ACT, or Acceptance and Commitment Therapy, is all about how to live the life that you want to be living, regardless of the internal or external problems that you might face. The acceptance piece is all about accepting the painful experiences of life, like loss, injury, sadness, fear, etc. because they are a natural and healthy part of life. The commitment piece is identifying what are the important parts of your life, and how can you commit to those parts of life.

ACT is considered a 3rd wave psychotherapy, and in many ways it’s meant to be an update on 2nd wave, CBT therapies. The simplest way that I think about it is that CBT is more about making the bad stuff – anxiety, depression, anger – go down, whereas ACT is more about making the good stuff – quality of life, goals, values – go up. Now, I think most good therapy will both try to decrease the negative and increase the positive, so the difference is really on the focus. I like ACT when the central feature of the presenting issue is something immovable, like grief/loss, terminal illness, Severe Persistent Mental Illness, or ice powers that go out of control when you’re afraid.

What’s the ICD-10 code for that?

With Elsa, we can skip some of the goals and values clarification aspects of the treatment, because it’s basically written in stone that she needs to move towards increasing the love in her life. So therapy becomes about identifying ways to do that. Values in ACT are kind of like a compass heading, in that you keep moving in that direction, but there’s no final destination to reach. ACT talks about finding “values based actions” and the movie talks about “acts of true love”, so we just have to find out what that means for Elsa. Spending time with her sister, helping her subjects, probably even dating are all on the table.

I’m also not letting her leave my office without finding some better ways to cope with her fear. Even after she was told that “Fear is the enemy”, she never got an real guidance about how to deal with that fear, beyond “here, wear some gloves.” So I would introduce her to my MEDIC. There’s also a technique called anchoring which would be particularly helpful.

Anchoring

Anchoring is all about classical conditioning, where you associate a benign stimulus with a certain response. Pavlov’s dog associated the ringing of a bell with salivating. When you do this on purpose, you can associate some kind of object with a particular feeling. Catholics often pray on their rosary beads, so the beads themselves become associated with feelings of tranquility and hope. With Elsa, we would choose some kind of talisman, maybe a locket, to serve as a reminder of her feelings of love. We would pick some kind intentional practice meant to elicit these feelings, like spending time with her sister, and then make sure she holds the locket during these practices. As the locket becomes associated with the feeling, it can elicit the feeling by itself during times of stress.

“The Ice Queen’s Talisman”

+1 Cold Resistance

My big caveat here is that I don’t know if this works. The theory behind anchoring is pretty sound, but the concept was developed as part of a treatment called neurolinguistic programming (NLP), which is not very well regarded in the psychotherapy world. I couldn’t find any studies that looked at anchoring by itself, but the studies that looked at NLP were not very positive.

Prognosis

Excellent. In the first act of the movie, Elsa and her parents got one treatment recommendation: “Fear will be your enemy.” They spend the next 10+ years reorganizing their entire lives, and the management of their whole kingdom around that one treatment recommendation. That’s the kind of treatment adherence that therapists dream about at night. Now, imagine if they had put that kind of effort into something that would actually help!

ACT has been shown to be effective in mixed anxiety disorders, so I feel confident in this treatment, and Elsa is well supported by her family, which is a huge predictor of success. Anyway, now I have to go bang my head against a wall so that “Let it Go” doesn’t stay stuck in my head for the next week.

You’re welcome!

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