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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

Part of the problem with psychoanalyzing fictional characters is that you can’t judge them based on our own system of morality and ethics. The first clinical issue that I encounter with treating Ms. Lannister is that she comes from a different culture, and I am not culturally competent to treat individuals from Westeros. So while over the course of 7 seasons and 5 books we see her commit such horrible actions as orchestrating the murder of her husband and the mass murder of her own people at the Sept of Baelor, we can’t really consider these symptomatic actions just because they don’t match our moral system. They are crimes and atrocities, but they may not be symptoms. The best example of this might be her incestuous relationship with her twin brother, Jaime. While in our culture this is considered the height of taboo relationships, and indeed within her own religion this also considered an immoral relationship, there is a significant precedent for kings and queens to marry brother to sister. In her own words: “The Targaryens wed brothers and sisters for three hundred years to keep bloodlines pure.”

On the other hand, cross-cultural research tells us that the incest taboo is generally pretty universal. Still, where treatment differs from diagnosis is that we don’t necessarily think about what someone is doing that’s wrong or weird or different, so much as the behaviors or symptoms that are keeping them from being successful. And we hit another roadblock here, because Cersei is extremely successful! She is one of the most powerful single individuals in the entire world of Game of Thrones (or A Song of Ice and Fire) and the first ruling queen in the history of Westeros.

Having said that, she could be doing a whole lot better than she is. She has consistently brought herself and her kingdom to the absolute brink of catastrophe, and at this very moment in the series she is undermining what may be humanity’s best hope for surviving literally the end of the world.

What’s interfering is appears to be her exaggerated sense of her own importance and skill, her suspiciousness of others that rises nearly to paranoia, and her tempestuous emotions that lead to severe impulsivity. Other articles have diagnosed Cersei with Borderline Personality Disorder or Narcisstic Personality Disorder, and rather than retreading these articles to talk about the particular criteria, I’m going to dive into treatment.

Goals of Therapy

In good therapy, goals are agreed upon collaboratively by client and therapist. This is probably going to be the single greatest challenge in this treatment, as Cersei has shown time and time again how resistant she is to advice or guidance. Even for a hypothetical situation, it’s hard to imagine someone like Cersei – a woman who will literally sacrifice the entire world for pride – swallowing that pride long enough to come into a therapist’s office. But let’s say for the sake of argument that she was somehow compelled to sit with me.

It’s pretty common in therapy to see someone who doesn’t want to be there. Whether it’s a kid dragged in by their parents (or spouse by a spouse), or someone who is court ordered, or someone hospitalized, often the people that we’re treating don’t really want the treatment. The key is to focus on empathy for the situation that this person is in.

For Cersei, there’s a wealth of suffering that sits behind the arrogance and spite. Part of the brilliance of GRRM’s writing and Lena Heady’s portrayal is that they don’t reduce Cersei to a single dimension, and you can sense the feelings of isolation, fear and loss that inhabit this character. After all, this is a woman who lost three of her children, who was abused by an entire city, and who finds herself surrounded by enemies at the end of the world.

Finding a way to reduce someone’s suffering can be a great way in to do some of the more important work on underlying issues. In Cersei’s case, I would also focus on her ability to make better decisions, which is to say less emotional decisions. I’d have to be tactful here, avoiding any kind of suggestion that she isn’t already making great decisions, but she does seem pretty self-conscious of her intelligence.

With intelligent, somewhat resistant clients, I also like to highlight their autonomy. “I can’t force you to do anything or think any way or feel any feeling,” I will say, “I’m going to say some things that I know and some things that really smart people have said, or some things that have worked for people going through something similar to you, and if that thing sounds good you can do it, and if it sounds like bullshit you can tell me and we’ll find the next thing.”

Once I’ve found my way in and built up her trust a bit, I might also talk about ways to work better with others. Probably I won’t get much traction here though. Cersei’s interpersonal problem is her aggressiveness – she absolutely has to have her way no matter the situation. For most people, this causes problems because either they can’t have their way and they pitch a fit, or people stop putting up with them. Most people aren’t literally a goddamn queen, though, so Cersei could conceivably get her way in all situations and not see any consequences from it. From her perspective, she’s really got no reason to change here.

Treatment Plan

The number one recommended treatment for Borderline Personality Disorder is Dialectical Behavioral Therapy. Cersei’s narcissistic traits mean that she’s not a slam-dunk case for this treatment. Most notably, one of the primary targets of DBT is self-harming behaviors, but Cersei is far too enamored with herself to ever do anything to herself. Still, there’s plenty to DBT that would be appropriate for her.

DBT has four modules, and I would start with Core Mindfulness. There’s a lot here that would be appropriate for her, but broadly this could help her connect with the present moment, rather than being stuck in the past with her losses or previous failures, or dreading what may be coming in the future. DBT also talks a lot about the concept of Wise Mind, which again has a lot to it, but this is where I would help her see that her snap decisions made out of anger or spite are getting in her own way.

DBT’s Distress Tolerance and Emotion Regulation have a lot to offer to reducing her suffering and emotional reactivity. The Core Mindfulness module tends to be a little more fundamental and conceptual, and it has a nice focus on self-awareness. These modules focus on the use of skills to keep yourself even keeled, but you have have the wherewithal to use them first. If I’ve built up enough trust and motivation at this point, I might bring in the Interpersonal Effectiveness Module to address her interpersonal problems, but I really expect that to be a no-go.

Prognosis

Poor. DBT, when it is done well, can help someone balance their uncontrollable emotions, mend their broken relationships, and learn how to function in a world that seems to be arrayed against them. It’s a pretty ideal treatment for her, but first she would have to do it.

Cersei thinks she is the smartest person in any room she walks into and that everyone that she doesn’t know is out to destroy her. DBT takes a lot of effort and a lot of work, and frankly Cersei has absolutely no reason to put in that work. Most people who come to this treatment have already found themselves at rock bottom – no friends, alienating family, unable to work, unable to manage their own lives. Maybe if I had gotten to her in the dungeon of Baelor’s sept, I could have gotten to her, but at this point she just has no reason to change.

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