Explore the psychological insights and therapeutic approaches derived from the movie Luckiest Girl Alive in this detailed case conceptualization analysis.
This is a case conceptualization about Ani, from the movie Luckiest Girl Alive (Barker, 2022), who suffered multiple traumas. Various assessments are planned to determine possible diagnoses including Post-Traumatic Stress Disorder (PTSD) comorbid with borderline personality disorder (BPD) and/or Complex Post-Traumatic Stress Disorder (CPTSD). Ani’s predominant symptoms are suggested to be reduced a combination of treatments including a phase-based approach, compassion-focused therapy (CFT), Skills Training in Effective Interpersonal Relationships Narrative Therapy (SNT), and Trauma-Focused Cognitive Behavioural Therapy (TF-CBT). After clarifying the treatment plan, potential challenges and countertransference are explored. The paper ends with a review on a peer case consultation.
Tiffani, who prefers to be called Ani, is a 35-year old female Caucasian adult. She has come in because a reporter asked about past traumas triggering an onset of subdued symptoms. She has never been to therapy and is skeptical of the process. Ani is engaged to be married to an upper-class Caucasian adult male. As a profession, Ani is a writer for a column and aims to be an editor in chief for the New York Times. Her boss is supportive of her career dreams and encourages her to speak her raw truth. Majority of her relationships sound superficial and competitive in nature. She holds high standards for herself and intensely criticizes herself and others. Ani seems to have one true friend, who wants her to fight for justice. Ani grew up without a father and has a strained relationship with her mother.
When Ani was an adolescent, she was a victim to multiple traumas in the span of about a week. She was raped while being intoxicated by three adolescent males one after the other in the same evening. Ani inquired to report these rapes to the principle with the support of a former teacher, however, she retreated after discovering that her mother would be informed.
Later that week, former friends bombed and performed a shooting at their high school that made National news. Ani witnessed them killing multiple students including two of Ani’s rapists, and severely injuring many others, including paralyzing the other rapist. Ani ended up killing the former friend with a knife to stop the shooting. After the shooting, rumours spread that she plotted the school attack and the rapist was idolized as a hero. Moreover, when her mother was informed of the traumas, she blamed Ani for getting drunk, dismissed her, and concerned herself about finances, lawyers, and negative social judgement. The stigmatization, mistreatment, lack of validation from others seemed to contribute to negative self-appraisal, dysregulated feelings, and interpersonal relationship difficulties.
Ani has intense activation responses and struggles to cope and regulate with emotions including bursts of anger, extreme anxiety, irritability, shame, helplessness, alienation, humiliation, guilt, rage, resentment, feelings of helplessness, and unfairness. Some triggers hearing the word “rape”, hearing or seeing a knife or knives, physically exerting herself, seeing intoxicated men starring at her, and information or news on former rapists or the school bombing/shooting. Ani often dissociates from the moment during activation responses. She typically responds maladaptively with impulsive and extreme behaviours for example sudden binge eating, destroying objects, yelling hurtful things. Distinct intrusive, fragmented memories of past traumas involuntarily and frequently are queued by internal feelings or thoughts, and external objects and her living rapist (who is famous). Soon after immediate overregulated responses, Ani aqueously suppresses most thoughts, professional overworks, intensely exercises, persists to have rough sex, and/or obsesses about information on her living rapist.
PTSD and CPTSD Assessments
The Clinician-Administered PTSD Scale for the DSM-5 would be administered to assess PTSD symptoms (Kolthof et al., 2022). Following, the self-report Post-Traumatic Cognition Scale would be used to measure negative beliefs about the self (Karatzia et al., 2018).
The International Trauma Questionnaire (version 2) is a self-report measure for CPTSD (Alpay & Çelik, 2022; Cloitre et al., 2021; Karatzia et al., 2018). This psychometric evaluation can help organize symptom clusters for PTSD and disturbances in self-organization (DSO).
BPD Assessments
The structured clinical interview for DAM-5 personality disorders (SCID-5-P) borderline subscale can help determine the classification of BPD (Kolthof et al., 2022). If the criteria are met, then BPD symptoms will be assessed with the Borderline Personality Disorder Symptom Index (Kolthof et al., 2022).
Furthermore, the Adult Attachment Projective Picture System (AAP) assesses how the traumatic events affected Ani’s current attachment statuses (Tarrochi et al., 2013). Before administering the AAP, a conversation about her former views on relationships before the traumatic events would take place.
Outcome Rating Scale (ORS)
The ORS would be used to monitor how Ani perceives the effectiveness of treatment through self-reporting on sense well-being in four areas: overall, personal, intimate relationships, and social relationships (Tarrochi et al., 2013). Because Ani has interpersonal difficulties, the ORS could help the clinician adjust aspects of therapy to fit her needs and wants.
DSM V PTSD Comorbid with BPD
According to the DSM-V-TR, Ani meets all the criteria for a PTSD diagnosis. She confronted and witnessed real and threated death, serious injury, and sexual violence (Alpay & Çelik, 2022; Briere & Scott, 2015). Her symptoms have been present for at least a month in the last 6 months and she has more than one functional impairment. Currently, she experiences 10/19 symptoms including: recurrent, involuntary and intrusive distressing memories; dissociative reactions, intense or prolonged psychological distress to internal or external cues (for example, visuals and sounds of knives and seeing the rapist); marked physiological reactions; efforts to avoid external reminders (the rapist); persistent negative emotional state; persistent inability to experience positive emotions, irritable behaviour and angry outbursts, and problems with concentration (Alpay & Çelik, 2022; Briere & Scott, 2015).
According to the DSM 5, a BPD requires a clear pattern of unstable interpersonal relationships, self-image, and impulsivity from early adulthood until the present day and five out of nine symptoms need to be met (Briere & Scott, 2015). Currently, three symptoms are met, which include Ani’s self-damaging impulsive behaviours through spending, sex, binge eating, and exercising; affect instability especially regarding irritability; and her inappropriate, intense anger that is difficult for her to control (Alpay & Çelik, 2022; Briere & Scott, 2015).
Complex PTSD
CPTSD is only recognized in the eleventh edition of the International Classification of Diseases (ICD-11), which is determined by the World Health Organization’s (Cyr et al., 2022). CPTSD has six symptom clusters including three PTSD clusters and three regarding disturbances self-organization (DSO): affect dysregulation, disturbances in relationships, and negative self-concept (Cloitre et al., 2021; Cyr et al., 2022; Karatzias et al., 2018). Interpersonal relationship difficulties include feeling close to others, maintaining relationships, and having distrust of others (Alpay & Çelik, 2022; Cyr et al., 2022). Moreover, attachment disorganization has also been found to contribute to CPTSD (Karatzia et al., 2018).
More information is needed to determine which diagnosis is the most accurate to her symptoms including childhood experiences, suicidal ideation and self-harming behaviours, former views on relationships before the traumatic events, present alertness to being harmed and/or fear of abandonment, and symptoms prior to traumatic events compared to possible changes after them (Alpay & Çelik, 2022). However, it is likely that she does not have just one disorder. There is a need to distinguish complex PTSD and PTSD and BPD as there are many overlapping criteria and symptoms (Herman, 2015). It is possible that all diagnoses could exist simultaneously (Cyr et al., 2022). Proceeding forward, the treatment will be focused on targeting the symptoms rather than diagnoses.
Ani could benefit from a multiphasic, multimodal, and transtheoretical treatment approach (Tarrochi et al., 2013) that is personalized and refined for her salient combination of symptoms (Cloitre et al., 2021). Treatments will involve a phase-based approach, compassion-focused therapy (CFT), STAIR Narrative Therapy (SNT), and Trauma-focused cognitive behavioural therapy (TF-CBT).
Phased-Based Approach
Herman (2015) described a general three-phase approach to treating clients who have suffered with trauma. The three phases include safety and stabilization, remembering and mourning, and reconnection (Alpay & Çelik, 2022; . These phases are not meant to be completed in a linear fashion, but to be addressed as needed for the client to be safe and ready throughout the process. This approach is effective for PTSD, CPTSD (Alpay & Çelik, 2022; Ashfield et al., 2020) and BPD (Karatzias et al., 2018).
CFT
Self-compassion is a useful adaptive coping strategy to combat the negative effects from trauma, which can foster post-traumatic growth (Munroe et al., 2021). Self-compassion skills result in a better understanding of oneself without negative judgment through kindness; positive perception changes of humanity; and increasing mindfulness about thoughts, emotions, and sensations experiences (Munroe et al., 2021).
SNT
This approach will address PTSD and DSO symptoms through traditional memory processing and disturbances regarding affect regulation and interpersonal difficulties (Cloitre, 2013; Cloitre et al., 2021). It focuses on strengths and successes in the past, which could help increase positive self-talk alongside CFT (Lee, 2006). This approach usually consists of 16 sessions.
TF-CBT
TF-CBT could be helpful to train emotional regulation skills (Karatzia et al., 2018) and has been known to be particularly helpful for survivors of sexual abuse (Alpay & Çelik, 2022). The main theories behind it include emotional processing, the cognitive model, and dual representation (Lee, 2004). Ani feels many types of emotions that are usually involuntarily triggered. This could be helpful to understand and give meaning to the triggers and patterns of maladaptive behaviours (Karatzias et al., 2018). The approach could help challenge pre-existing beliefs and reframe negative self-appraisals. Emotional processing of intrusive memories should become more manageable and inhibit reactivation or external triggers (Lee, 2004). The National Institute of Health and Care Excellence states that symptom reduction can be achieved in about 8-10 sessions (Kolthof et al., 2022).
The International Society for Traumatic Stress Studies recommends that interventions are geared towards improving cognitive restructuring, emotional regulation, psychoeducation, and anxiety management (Tarrochi et al., 2013). The combination of a phased-based approach is suitable for Ani to build trust and to provide safety (Herman, 2015). CFT can help positively reframe negative beliefs and schemas (Karatzias et al., 2018), increase emotional regulation (Ashfield et al., 2020), and combat Ani’s negative self-judgment, self-criticism, and feelings of guilt, shame, alienation (Munroe et al., 2021). This will hopefully balance out her perfectionist qualities. CFT success could drastically aid the effectiveness of TF-CBT (Lee, 2004). Further, SNT has proven to decrease symptoms like reexperiencing, affect dysregulation, relationship difficulties (Ashlfield et al., 2020; Kolthof et al., 2022), dissociation, hyperarousal, disturbances in meaning, behavioural and attentional dysregulation (Cloitre et al., 2011), which is the central to Ani’s symptom clusters mentioned in the case conceptualization. SNT interventions could also reduce PTSD symptoms (Ashlfield et al., 2020; Cloitre et al., 2021).
Common maladaptive emotional regulation strategies as a result from trauma is expressive suppression (Karatzia et al., 2018). One of Ani’s strengths is writing, therefore the CFT could build off that strength and increase her internal locus of control to encourage her to write her truth (Munroe et al., 2021). TF-CBT interventions will be implemented to address emotional processing of traumatic events to help with acceptance (Munroe et al., 2021). Specifically, cognitive restructuring could address relationship difficulties and disturbances in meaning (Cloitre et al., 2011).
Significant time in the beginning of therapy will be focused on Ani feeling physical and emotional safe sharing vulnerable and sensitive information. Before each treatment implementation, Ani and the clinician must secure their alliance and clarify the purpose(s) (Briere & Scott, 2015). In this first phase, eight SNT sessions will focus on teaching tools to stabilise herself, like introducing grounding techniques and psychoeducation on the PTSD symptoms (Briere & Scott, 2015). The first 8 sessions can focus on exploring how the trauma has affected her sense of self, relationships, stress coping mechanisms, and symptoms in relation to trauma (Cloitre, 2013). Frequent, normalizing of emotions can increase autonomy and awareness of symptoms (Herman, 2015).
The second phase will start the next 8 SNT sessions. The focus would be on increasing positive appraisal, strengthening coping mechanisms, and developing a safety plan (Cloitre, 2013). This could help Ani build her “window of tolerance” (Cloitre, 2103; Lee, 2004), while using CFT strategies (Ashfield et al., 2020). Adjacently, CFT can help with self-soothing skills (Ashlfield et al., 2020). This will include consistent validation and reassurance to increase self-esteem and autonomy.
The final phase will involve confronting the intrusive memories (Lee, 2004; Herman, 2015). Clear communication is needed to sort out any disagreements on opinions or the treatment process before entering the therapeutic window (Briere & Scott, 2015).
Treatment and assessments take time to conduct and report, which risks wasting time and money (Tarrochi et al., 2013). Furthermore, using multiple assessments risks revealing unwarranted results, which could put pressure on Ani to discuss it (Tarrochi et al., 2013). Although therapeutic assessments are time intensive, managed care companies could be willing to financially support a portion back for agreeing to this approach (Tarrochi et al., 2013).
Lack of research on CPTSD (Alpay & Çelik, 2022) and BPD (Kolthof et al., 2022) creates a challenge in understanding the origins of each disorder regarding childhood patterns, protective factors, risk factors, and treatment options. Further, their overlapping symptoms and diagnosis criteria creates uncertainty on treatment effectiveness. It is recommended to seek ongoing supervision and consultation for professional use of assessments and results (Tarrochi et al., 2013). Continuously using the ORS and debriefing the results throughout treatment will help determine Ani’s readiness for change and remaining sessions needed (Tarrochi et al., 2013).
Moreover, Ani’s tendency to be excessively suppressive could skew the ORS results. Therefore, the clinician should be mindful of nonverbal discrepancies. Additionally, Ani’s affect intolerance and extreme reactions could trigger the clinician emotionally. It is important that the clinician ensures safety for the client and themselves by avoiding negative countertransference, which can be achieved through clinician containment and refocusing attention to other feelings or injustices to demonstrate empathy and advocacy (Herman, 2015). Moreover, Ani’s negative self-concept could contribute to extreme resistance and a lack of responding to TF-CBT interventions and can be combated with CFT (Karatzia et al., 2018). To ensure further safety regarding countertransference, clearly setting a therapy contract that outlines goals, boundaries, and rules for the session must be adhered to (Herman, 2015).
Peer consultation lasted about an hour and a half. The group consisted of three colleagues. Each colleague emailed their rough drafts before the meeting and then verbally discussed their concerns. Many affirmations, ideas, and recommendations were exchanged. The most helpful information given was to focus the treatment modalities, rationale, and plan according to the symptoms rather than the potential diagnoses. This made it easier to incorporate a multimodal approach. One colleague shared appropriate personal experiences as a therapist and shared her knowledge specialized in dialectical behavioural therapy. There was an effort to persuade the usage of this treatment modality. Although it was convincing to be useful, the chosen combination of treatment modalities felt more than suitable. Learning how other colleagues interpreted the requirements of the paper was insightful to create and refine this trauma focused case conceptualization and address safety concerns. This learning process is at the heart of strong recommendations to seek out consultations (Briere & Scott).
Alpay, E. H., & Çelik, D. (2022). Complex Post-Traumatic Stress Disorder: A Review. Current Approaches in Psychiatry / Psikiyatride Guncel Yaklasimlar, 14(4), 589–596. https://doi.org/10.18863/pgy.1050659
Ashfield, E., Chan, C., & Lee, D. (2021). Building “a compassionate armour”: The journey to develop strength and self‐compassion in a group treatment for complex post‐traumatic stress disorder. Psychology & Psychotherapy: Theory, Research & Practice, 94, 286–303. https://doi.org/10.1111/papt.12275
Barker, M. (Director). (2022). Luckiest Girl Alive [Film]. Made Up Stories, Orchard Farm Productions, and Picture Start.
Briere, J. N., & Scott, C. (2015). Principles of trauma therapy: A guide to symptoms, evaluation, and treatment (2nd ed.). Sage.
Cloitre, M. (2013). The case: Treating Jared through STAIR Narrative Therapy. Journal of Clinical Psychology, 69(5), 482-484. https://search-ebscohost-com.libraryservices.yorkvilleu.ca/login.aspx?direct=true&AuthType=url,cookie,ip,uid&db=pbh&AN=86980703
Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24(6), 615–627. https://doi.org/10.1002/jts.20697
Cloitre, M., Hyland, P., Prins, A., & Shevlin, M. (2021). The international trauma questionnaire (ITQ) measures reliable and clinically significant treatment-related change in PTSD and complex PTSD. European Journal of Psychotraumatology, 12(1), 1–12. https://doi.org/10.1080/20008198.2021.1930961
Cyr, G., Godbout, N., Cloitre, M., & Bélanger, C. (2022). Distinguishing Among Symptoms of Posttraumatic Stress Disorder, Complex Posttraumatic Stress Disorder, and Borderline Personality Disorder in a Community Sample of Women. Journal of Traumatic Stress, 35(1), 186–196. https://doi.org/10.1002/jts.22719
Herman, J. L. (2015). Trauma and recovery. BasicBooks.
Karatzias, T., Shevlin, M., Hyland, P., Brewin, C. R., Cloitre, M., Bradley, A., Kitchiner, N. J., Jumbe, S., Bisson, J. I., & Roberts, N. P. (2018). The role of negative cognitions, emotion regulation strategies, and attachment style in complex post‐traumatic stress disorder: Implications for new and existing therapies. British Journal of Clinical Psychology, 57(2), 177–185. https://doi.org/10.1111/bjc.12172
Kolthof, K. A., Voorendonk, E. M., Van Minnen, A., & De Jongh, A. (2022). Effects of intensive trauma-focused treatment of individuals with both post-traumatic stress disorder and borderline personality disorder. European Journal of Psychotraumatology, 13(2), 1–12. https://doi.org/10.1080/20008066.2022.2143076
Lee, D. (2006). Case conceptualisation in complex PTSD: Integrating theory with practice. In Case formulation in cognitive behaviour therapy (pp. 158-182). Routledge.
Munroe, M., Al-Refae, M., Chan, H. W., & Ferrari, M. (2022). Using self-compassion to grow in the face of trauma: The role of positive reframing and problem-focused coping strategies. Psychological Trauma: Theory, Research, Practice, and Policy, 14(S1), S157–S164. https://doi.org/10.1037/tra0001164
Tarocchi, A., Aschieri, F., Fantini, F., & Smith, J. D. (2013). Therapeutic Assessment of Complex Trauma: A Single-Case Time-Series Study. Clinical Case Studies, 12(3), 228–245. https://doi.org/10.1177/1534650113479442
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