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Journal of Child & Adolescent Trauma logoLink to Journal of Child & Adolescent Trauma
. 2019 May 6;12(4):561–570. doi: 10.1007/s40653-019-00258-0

Treating a 16 Year Old with a History of Severe Bullying: Supplementing Cognitive Behavioural Therapy with EMDR within the Context of a Case Formulation Approach

Alice Taylor 1,2,✉, Niel H McLachlan 1
PMCID: PMC7163813  PMID: 32318222

Abstract

This article describes the use of a case formulation approach, integrating evidence-based treatment in the context of individual clinical traits. It focuses on the supplementation of cognitive behavioural therapy (CBT) with eye movement desensitization and reprocessing (EMDR) in the treatment of a young person, presenting with an initial diagnosis of obsessive-compulsive disorder (OCD). A case formulation suggested the possibility of a differential diagnosis of Adjustment Disorder, indicating the usefulness of the addition of EMDR sessions to process memories of severe bullying. Previous studies promote the idea of using EMDR in cases that do not meet the threshold for Post-Traumatic Stress Disorder (PTSD), in order to reduce the presentation of anxiety. Earlier research suggests that each of these models has specific strengths and attributes in the treatment of mental health difficulties and, whilst based within the context of a well-established case conceptualisation, can be effectively integrated.

Keywords: Adolescent, EMDR, Cognitive behavioural therapy, Integrative approach, Differential diagnosis

Within traditional mental health models, a diagnosis can determine the method of intervention, often targeting the most problematic symptoms and daily functioning difficulties (Johnstone 2018). It can be helpful for clinicians across different services to have a standard set of common symptoms to recognise and treat (Stein et al. 2013). This can allow for the most effective evidence-based interventions to be identified and applied for an individual’s difficulties. However, these classification systems have been criticised for low reliability and validity (Kendell and Jablensky 2003; Slade and Andrews 2001). The criteria of the DSM-5 and ICD-10 (APA 2013; WHO 2016) assume categories of mental health diagnoses, distinct from each other and physical health. This does not account for common symptoms across mental health difficulties, nor the presence of some symptoms in the general population (Hyman 2010). The sole use of diagnosis-led treatment can often lead to a misdiagnosis of mental health difficulties, which in turn can negatively affect the treatment plan (Macneil et al. 2012; NICE 2013).

Within psychology, the use of case formulation has often been suggested to avoid the limitations of a purely diagnostic approach, instead using a holistic approach to identify what treatment components may be best suited for particular individuals (Johnstone 2018). Formulation is described as a core clinical skill for psychologists, with the collaboration of therapist and service-user as a key feature of informed intervention (Division of Clinical Psychology 2011). The therapist and service-user collate information to form hypotheses about the development and continuation of the service-user’s difficulties (Johnstone 2018). Formulation is continuous and is often adapted as new information becomes available, consequently informing interventions (Eidelman et al. 2018). As many mental health difficulties are considered to have high co-morbidity with others, the case formulation approach may bypass the difficulty with a medical model of treating only the most acute symptoms and instead focus on the individual as a whole (Persons et al. 2006; Esbjørn et al. 2015).

In line with the above discussion, the aim of this article is to stress the importance of the formulation process in managing complex symptom presentations. The process of formulation/reformulation allows for the integration and timely introduction of different treatment models and components in therapy.

Trauma in Obsessive Compulsive Disorder

Many theories suggest an involvement of previous trauma experiences in the development of multiple mental health disorders, including PTSD, depression and OCD (Cromer et al. 2006). The distress associated with previous traumatic experiences may motivate a series of behavioural and cognitive responses intended to reduce distress in the short term, however these can have the consequence of preventing cognitive change and therefore maintaining the difficulties (Johnstone and Dallos 2013). It has long been recognised that there may be a link between exposure to traumatic events and the development of OCD symptoms, whether due to classical conditioning to avoid distress, adjustment difficulties, or as a reaction to emotional shock (de Silva and Marks 1999). Research has described the emergence of obsession-like symptoms initially related to recent distressing events, which can then develop into independent obsessions and compulsions (Fostick et al. 2012). Studies suggest a particular link between exposure to traumatic experiences and the development of OCD-like symptoms in individuals who may struggle with avoidant attachment styles, adjustment and alexithymia (Carpenter and Chung 2011; Flett et al. 2011). Case formulation that includes the assessment of life stressors is essential in making collaborative decisions about the next steps for care.

Interventions

In the treatment of OCD symptoms, CBT interventions emphasise the importance of dealing with discomfort caused by obsessions and the reduction of compulsive rituals (NICE 2014). Exposure with response prevention (ERP) is established as one of the main interventions for the treatment of OCD symptoms (NICE 2014). This approach gradually exposes individuals to their obsessive thoughts, whilst encouraging them to abstain from the compulsions normally used to reduce the distress (Franklin and Foa 2011). The aim is to help the individual to tolerate distress related to the obsessions and reduce their compulsive/ritualistic behaviours (Franklin and Foa 2011). Studies have long reported the efficacy of this approach in reducing OCD symptoms and long-term anxiety associated with distressing thoughts (Olatunji et al. 2013).

Whilst ERP is the main cognitive behavioural approach for treating OCD, some individuals appear to be resistant to this evidence-based treatment (Pozza et al. 2014). Research has suggested that there may be a higher prevalence of past traumatic experiences in individuals diagnosed with treatment-resistant OCD, and that these experiences may reduce the effectiveness of common interventions for OCD (Gershuny et al. 2008). Some qualitative evidence links particular OCD obsessions to the context of traumatic events, e.g. feeling ‘unclean’ after sexual assault (Fostick et al. 2012; Marsden et al. 2018). Despite the link between trauma and development of OCD, and similarities in the treatment of PTSD and OCD, it appears that interventions for OCD do not have an established protocol for addressing the influences of previous trauma (Dykshoorn 2014). Eye movement desensitization and reprocessing (EMDR; Shapiro 2001), originally used as an intervention for post traumatic stress disorder (PTSD) could be adapted for treating other mental health difficulties associated with distressing memories. Preliminary and limited research has suggested the effectiveness of EMDR components in reducing symptoms of anxiety, OCD and depression, where stressful life events may have caused the onset of mental health difficulties (Marr 2012; Wood and Ricketts 2013). Theories which propose the development of such difficulties as a result of unprocessed trauma may advocate the efficacy of EMDR to process the traumatic material and therefore reduce the difficulties associated (Marsden et al. 2018; Marr 2012).

Comparison of Interventions

Both CBT and EMDR should be regarded as distinct approaches with commonalities and differences (Beer 2014). Both methods have seen support for the efficacy of their techniques (de Roos et al. 2011; Jaberghaderi et al. 2004). Diehle et al. (2015) found in their randomised controlled trial, that both treatments (EMDR and CBT) were effective in children with post-traumatic stress symptoms. The CBT condition appeared to be more effective in addressing comorbid problems compared to EMDR and although not significant, a slightly shorter treatment course was observed for EMDR. Theories surrounding CBT hypothesise that OCD symptoms may be a consequence of conditioning to a fear-stimuli; the appraisals and expectations of fear-stimuli act to negatively reinforce any behaviour which avoids exposure to distress caused by fear-stimuli. In order to challenge this conditioning, the appraisals and expectations of the fear stimuli must be restructured, by exposing individuals to corrective information (Reddy et al. 2017). Theories in support of EMDR however, suggest that mental health difficulties may arise when traumatic memories are not correctly processed and stored, therefore resulting in emotional, cognitive and behavioural dysfunctions (Shapiro 2001). Based on the underlying theories for the development of mental health difficulties, CBT and EMDR differ in the focus of their treatments. CBT emphasises interventions based on the current presentation and symptoms, using in vivo exposure to fear stimuli and habituation to the accompanying distress response. On the other hand, EMDR interventions centre on reappraisal and reprocessing of previous traumatic memories, indirectly reducing the current mental health symptoms as distress reduces.

Limited research supports the efficacy of an integrated CBT and EMDR approach within the context of trauma. In their treatment of a 16 year old with acute stress from trauma, Bronner et al. (2009) combined EMDR with CBT with positive effect. Following a CBT component of treatment, the client continued to experience difficulties including elevated levels of anxiety and sleep problems, which the authors considered as an indication to introduce an EMDR session. At follow up, the client reported a reduction in hyperarousal symptoms and anxiety, as well as improvements in relation to the experiencing of flashbacks and sleep difficulties. Hettiarachchi (2007) combined CBT and EMDR in her treatment of an adult survivor of the Asian Tsunami of December 2004. The cognitive component of the treatment focused on self-help skills whilst EMDR involved supporting the client to express and process emotional content. Follow-up of the client nine months later, showed subclinical scores on a number of outcome measures.

Commonalities between the two treatment procedures include the use of psycho-education, emotion regulation and coping strategies, exposure, and the processing of emotions and cognitions (Schnyder et al. 2015). Jeffries and Davis (2013) state that a CBT approach for the majority of mental health difficulties consists of elements of exposure, i.e. imaginal, narrative writing or in vivo exposure, combined with cognitive interventions that focus on the meanings attached to the difficulties. Others suggest similar elements of imaginal exposure, guided self-dialogue and cognitive restructuring within the process of EMDR, (Gunter and Bodner 2008; Herbert 2002). Although many of the procedures and protocols incorporated in EMDR overlap with CBT, one of the distinctive elements of EMDR is dual attention. This involves the client focusing on part of a traumatic memory, whilst concurrently engaged in an external task, i.e. bilateral stimulation in the form of eye movements. Theories suggest that the process may help to reduce the vividness of the traumatic memories (Schubert et al. 2016), or facilitate increased interaction between the left and right hemispheres for improved memory processing (Propper and Christman 2008).

Although both approaches promote exposure to allow reappraisal of fear; the different types of exposure promoted by CBT and EMDR may be best suited to different people, i.e. verbal or in vivo exposure in CBT may be too overwhelming for some, therefore encouraging the use of the dual attention exposure method in EMDR. It may also be that the use of holistic formulation within CBT is valuable for many aspects of treatment, whereas the specific focus of EMDR on one aspect of a person’s life may highlight the significance of some events over others, i.e. some traumatic material may seem more relevant to the presenting problem, as seen in this case study. Despite the differences in the interventions and underlying theories, similarities between the approaches are essential to allow for integration of procedures without interfering with the integrity of either approach.

It is hypothesised that the commonalities and differences between CBT and EMDR may allow the integration of treatment components in several ways; (1) focus on the multiple and differing aspects of the development and maintenance of mental health difficulties, (2) promote a person-centred and collaborative approach to psychological treatment, based on individual symptoms and (3) allow flexibility within the fidelity of each treatment approach. This article aims to discuss, by means of a case example, how EMDR can be employed to supplement a CBT approach when treating OCD-like symptoms in the context of adjusting to distressing past experiences. Research has highlighted the value of collaboration, emphasis on individual needs and the integration of several components of treatment (Hamilton et al. 2008; Triscari et al. 2015; Beaumont et al. 2016). This case example follows a 16 year old girl with a history of severe bullying and subsequent obsessive-compulsive behaviours. Treatment of her difficulties, based on the case formulation, included the introduction of medication (Sertraline) and EMDR to facilitate the processing of difficult bullying memories. CBT was used to challenge previously held beliefs and ERP targeted unhelpful maintenance behaviours.

Case Example

Background

Enid was first referred in 2014, by the local hospital to the Child and Adolescent Mental Health (CAMHS) Duty Team following a medication overdose. The overdose was triggered by her boyfriend breaking up with her. Enid was seen for three sessions employing a problem-solving approach and was discharged. She was re-referred in 2015 after presenting with panic attacks, obsessional behaviours, suicidal ideation, low mood and self-harming. Enid was attending college for the first time, and was worried about becoming the victim of bullying again, falling out within her peer group, and had concerns that her parents may separate. Of note, the patient gave full consent to her clinical data being shared in this publication. The authors have anonymised certain personal information in order to protect the patient’s privacy.

Assessment

Enid was preliminary diagnosed as having OCD presenting with an inflated sense of responsibility and obsessional thinking regarding appearance. Enid reported that she felt responsible for preventing the separation of her parents, and further held the belief that she always had to look her best in order to be accepted within a social context. In addition, Enid expressed concerns about catching germs and becoming ill, as being physically unwell could result in others not wanting to be around her. As a result, her compulsions included excessive checking and hand-washing, as well as applying her make up in a rigid, time consuming manner. In addition, Enid was scared of offending others and opted to be non-assertive, i.e. not sharing her opinion in social situations in order to prevent conflict and potential rejection.

Enid’s score on the Child Yale-Brown Obsessive Compulsive Scale (CYBOCS; Goodman et al. 1991), used to assess symptoms of OCD, was 35 (within the extreme range). The link between her compulsive behaviour, e.g. rigid application of her make-up before leaving the house, and negative past experiences within her peer group resulted in the therapist considering some of Enid’s compulsive behaviour to be linked to negative memories. Based on this initial clinical observation, the proposal of a differential diagnosis was also considered, and Enid was asked to complete The Child Revised Impact of Event Scale −13, used to assess symptoms of PTSD (CRIES; Perrin et al. 2005). The application of the CRIES was used as qualitative exercise in order to substantiate initial observations regarding the negative impact of past bullying experiences on Enid, and resulted in a score of 63 (clinical cut off: 30).

Preliminary Formulation

Within the context of self- harm, suicidal ideation and feelings of sadness, the diagnosis of a mood disorder was considered. However, Enid continued college attendance, had a healthy appetite and good sleep pattern in spite of her difficulties. Considering this, it was decided to focus on a diagnosis of obsessive-compulsive disorder (OCD) instead. Salkovskis’ model of OCD proposes inflated responsibility during childhood as the primary pathway to the development of OCD related beliefs (Salkovskis and Kirk 1999; Collins and Coles 2018). Initially, this model was considered to formulate Enid’s difficulties; however, it is not uncommon for young people with a history of traumatic memories to develop concerns about harm to themselves and/or others accompanied by compulsive rituals meant to prevent these negative outcomes (Smith et al. 2010; Cromer et al. 2006; Kroska et al. 2018). Whilst exploring Enid’s obsessions regarding appearance, her history of bullying in secondary school and its impact on her OCD related beliefs became apparent.

As part of the preliminary formulation of a young person’s difficulties, Smith et al. (2010) emphasise the importance of obtaining a narrative account of distressing events to help identify peri-traumatic misappraisals (Johnstone 2018). In her account of the bullying experience, Enid recalled seeing herself walking alone in school, going home alone, and others shouting abuse and laughing at her. As a result, she described herself as “becoming more and more closed off.” In addition, Enid shared that she always felt scared and sad. Enid’s appraisal of herself included being unlikeable and disappointed in herself, as in her judgement, she should have been better at standing up for herself. She also viewed herself as weak for feeling sad and lonely as a consequence of her experiences.

Enid also shared that her parents had often argued in the past and that she was worried about them separating whilst growing up. Enid appraised these situations as her responsibility to stop them fighting and to prevent them from separating, i.e. “I should have stopped it sooner.” Although Enid acknowledged the importance of these memories in the development of her difficulties, she felt that the incidents of bullying were more central to the maintenance of her worries. It was therefore decided that the memories of her parents’ arguments were not a key area of focus for intervention.

In addition, it is argued that it is important to focus on the young person’s current coping style to identify avoidance and safety seeking behaviours which may maintain the problem (Levy and Radomsky 2016; Alonso Tapia et al. 2016; Smith et al. 2010). Based on her bullying experiences, Enid constantly worried about losing friends and offending others. To compensate for this, she over focused on appearance and rigidly applied her make up as a safety seeking behaviour. She would also frequently check and recheck herself in the mirror to ensure that she looked her best so that others would not find her unacceptable and therefore unlikeable. In order not to offend others, Enid also avoided expressing her own opinions too strongly in peer conversations which in turn confirmed her beliefs of being weak. Additionally, in the context of responsibility for her parents’ situation, i.e. “I should have stopped it sooner” and in order to prevent further negative outcomes, Enid developed a number of compulsive rituals and safety seeking behaviours in the form of excessive checking, which then became habitual (e.g. checking that she did not cause damage to the house by leaving appliances plugged in).

Treatment

Due to the severity of Enid’s difficulties and subsequent distress (CYBOCS: 35), Enid was prescribed Sertraline by a CAMHS psychiatrist prior to her starting therapy. Treatment was initially focused on risk management, addressing Enid’s suicidal ideation and reducing self-harm, before attending to the symptoms of OCD, based on the case formulation. It was hypothesised that thoughts of peer rejection resulted in Enid experiencing low mood. When low in mood, Enid resorted to self-harming and compulsive behaviour, e.g. trying not to offend others and excessive checking. A safety plan was agreed with Enid and her parents and she was encouraged to talk to her parents and college counsellor when feeling low in mood and wanting to self-harm between sessions. In addition, Enid had access to the Child and Adolescent Mental Health Duty Service (CAMHS) which offered 24/7 support. However, Enid never used this service. Having a better understanding of the mechanisms maintaining her self -harm allowed Enid to discuss her feelings more openly in therapy and she stopped self-harming after three sessions. Upon abstinence from self-harm, and after an explanation of the rationale for treatment (session four), CBT with exposure response prevention was introduced in session five to start treating Enid’s OCD symptoms. As a first step, Enid was asked to gradually reduce the amount of time she spent on her make-up before attending clinic and college. However, no significant progress was made. Enid continued to hang onto unhelpful safety behaviours such as wearing ‘perfect make-up’, and experiencing distress when thinking about interacting with peers at college. She also held strong beliefs about being ‘disgusting and unacceptable’ and therefore feared being rejected.

Expanded Formulation

Based on this presentation, a differential diagnosis of Adjustment Disorder (DSM-V: American Psychiatric Association 2013) was considered, as a response to the identified stressor of previous severe and prolonged peer group bullying (see Fig. 1: Beck 1995). Although a diagnosis of Post-Traumatic Stress Disorder (PTSD) was considered, Enid did not meet full criteria for such a diagnosis, i.e. exposure to actual or threatened death, serious injury or sexual violence.

Fig. 1.

Fig. 1

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Longitudinal Formulation (Beck 1995)

Adjustment Disorder is characterised by an excessive and intense reaction to adverse stressful life events and can result in problems with social or occupational functioning or other mental health difficulties (American Psychiatric Association 2013). Adjustment Disorder and poor social adjustment are common co-morbid diagnoses for OCD (Bolton et al. 1995; Rosa et al. 2012). Although Adjustment Disorder in adults is thought to be relatively short-lived and symptoms may reduce with the removal of the stressor, it can also lead to associated long term difficulties and can increase the risk of suicide (Bentley et al. 2016). It is suggested that the treatment of co-morbid anxiety may be more difficult to treat if difficult or traumatic memories are present (Smith et al. 2010; van Nierop et al. 2015). It appeared that Enid had a preoccupation with the memories of her bullying, making it difficult for her to process her distress and adapt accordingly (Glaesmer et al. 2015). Due to Enid’s prolonged isolation, low mood and anxiety leading to a subsequent diagnosis of Adjustment Disorder, it was agreed that a priority of future intervention was the processing of difficult memories.

Treatment Adjusted Based on Expanded Formulation

Guided by elements of narrative focused CBT, treatment focused on the creation of a script and processing of associated emotional and cognitive distress (Smith et al. 2010; de Roos et al. 2011). Enid was guided to participate in Safe Place Imagery (Shapiro 2001; Gilbert 2010), in which she identified a local lake and its surroundings as her safe place. Revisiting her Safe Place was employed at the end of reliving sessions to support Enid in de-escalating her levels of physiological arousal. During reliving, Enid shared that the experience made her feel sick, angry and sad. In line with Sydenham et al.’s (2017) argument regarding unhelpful perfectionism, Enid believed that feeling sad meant that she was weak and left her vulnerable to others taking advantage of her. Cognitive restructuring enabled Enid to accept negative affect and to view her new friendship group at college as caring.

In spite of her progress, Enid continued to experience nightmares related to the past bullying and complained of a reoccurring image of peers laughing at her and throwing food at her in the school cafeteria. According to Lee et al. (2001), anger, shame, guilt and humiliation are frequently associated with traumatic events. Gilbert (1997) argues that humiliation arises from experiences where an individual has been in a powerless position and feels ridiculed. Individuals in these situations often ruminate and replay acts of humiliation in their mind. This can also be accompanied by an escalation of anger. Although narrative exposure can be effective for fear, humiliation and anger often require the addition of specific psycho-education and cognitive restructuring components (Lee et al. 2001). The therapist introduced psycho-education and cognitive restructuring as part of CBT.

In order to challenge Enid’s beliefs that she had disappointed herself for not being able to stand up for herself, she was encouraged to imagine her 12 year old self experiencing these events, and was guided to being compassionate to herself (Gilbert 2010; Kroska et al. 2018), i.e.”What would you like to say to 12 year old Enid now?” This exercise enabled Enid to replace her self-criticism with a refocused self-compassion, i.e. “Enid you were doing OK to keep going, you were brave and you don’t need to be hard on yourself.” In spite of this initial progress, Enid was frustrated with her inability to shift her feelings of helplessness and humiliation, i.e. “nothing seems to help”. Although many of the procedures incorporated in EMDR overlap with CBT, a distinctive element of EMDR is dual attention. According to Herbert (2002), this allows for the client to simultaneously experience images, cognitions, affect and bodily sensations. It is further argued that bilateral stimulation facilitates attention to the trauma memory without avoidance and allows for input of new trauma related information (Jeffries and Davis 2013). Taking Enid’s frustration into account, as well as the fact that the incident in the cafeteria was considered to be a stand-alone memory, it was decided to introduce EMDR to support emotional processing (Herbert 2002; de Jongh et al. 2010).

Following clarification of the procedure, Enid indicated that she did not want to engage in eye movements, stating that it would not be appropriate for her, “I don’t like it.” As Enid expressed that hand tapping by the therapist (one alternative to eye movements) would feel too intrusive, the Butterfly Hug (BH) was introduced as dual attention stimulation (Jarero et al. 2008). This involved Enid crossing her arms over her chest and placing her hands just below her collarbone, optionally linking thumbs to create a ‘butterfly’, allowing her hands to lightly tap on her chest (Jarero et al. 2008). There is evidence that BH has similar efficacy as eye movement or hand tapping (Artigas and Jarero 2013), and it may be deemed especially useful, as it can be self-administered and does not need therapist involvement if the client becomes distressed outside of sessions (Settle 2016). Enid was asked to focus on the most distressing image of her memory – people laughing at her in the cafeteria. She identified “I am weak” as her negative cognition and her positive belief was “I am OK now.”

Enid identified the emotion associated with this image as humiliation and she reported feeling this distress foremost in her stomach as a sick feeling. Enid was instructed to recount the event in the cafeteria out loud, from just before the incident took place up to the end of the memory whilst performing the BH. This process lasted for approximately 20 min with Enid reporting people not appreciating how difficult things were for her, to concluding that her brother did come down from university to support her and her father was very understanding. However, Enid continued to express feeling helpless and sick during BH, resulting in the therapist introducing a cognitive interweave; “Who has the power now?” before asking Enid to repeat the process (BH) again (approximately 15 min). At the end of two more sets, Enid reported a marked improvement with a subjective level of distress of 0. Thereafter the positive cognition was installed. The session lasted for approximately 90 min in total and Enid reported feeling very tired but relieved.

Following the above intervention, Enid was seen for a further five sessions, employing a CBT approach for OCD (Van Niekerk 2009; Katz et al. 2018). Enid’s inflated sense of responsibility for negative consequences, i.e. being responsible for becoming ill and starting a house fire, was challenged by focusing on OCD thinking devices and the alternative common sense view (Van Niekerk 2009). The thinking device, distrusting your senses, combined with developing a common sense view, were used to challenge Enid’s obsessional thinking and associated rituals (Van Niekerk 2009; Guzick et al. 2018), e.g. “Even though I can see the switch is off, I might not have looked carefully enough” changed to “I could hear the switch go off” “Germs make me ill” changed to “Not all germs are bad. It is good for the immune system to be exposed to germs.”

Exposure and response prevention, structured in the form of behavioural experiments, was used to address Enid’s concerns about her appearance and to reduce the time she spent applying her make up (Rector et al. 2018). Initially these experiments were conducted in clinic, i.e. Enid not wearing make up to clinic as a first step and reflecting on the responses from others in reception and the waiting room area. This was followed by her gradually not wearing make up to college and when out in public. Throughout these experiments, Enid concluded that others did not respond in any negative or rejecting manner towards her, i.e. “nothing happened, no-one said anything.”

Although the therapist suggested the inclusion of her parents in therapy on a number of occasions, Enid declined this offer. Based on her age, level of development and functioning, i.e. college attendance and having weekend employment, it was decided to respect Enid’s wishes. The three phases of treatment, i.e. CBT, EMDR and CBT for OCD, involved a total of 16 sessions. Part of the final session focused on relapse prevention and Enid was discharged back into the care of her general practitioner (GP) who also monitored medication (Sertraline).

Outcomes

In order to monitor progress, Enid was encouraged to offer feedback about the usefulness of sessions and improvements she had made. As sessions progressed, Enid reflected on her ability to challenge unhelpful self-beliefs about her being unacceptable within the peer group setting. She was able to form new friendships and also felt more confident going out without having to apply make-up in a compulsive manner. Enid was also able to leave the house without having to check whether appliances were switched off. In addition, Enid denied suicidal ideation as therapy progressed and stopped self-harming within three sessions.

At this stage, end of treatment outcome measures were also completed and comparisons were drawn between pre, mid and post treatment measures. Enid’s pre-treatment score of 63 (cut off: 30+), on the Child Revised Impact of Event Scale −13 Item (CRIES; Perrin et al. 2005), reduced to 22 at mid-point and 5 at the end of treatment (below the clinical range). Her score on the Children’s Yale Brown Obsessive Compulsive Scale (CYBOCS; Goodman et al. 1991) reduced from 35 (pre-treatment) to 5 at the end of treatment (sub-clinical range). These outcomes were used as further evidence of progress within therapy.

Enid was reviewed at a one month follow-up where she reported ongoing positive progress, i.e. college attendance. During a telephone consultation, a further 3 weeks later, Enid reported that she had enrolled herself into the second year of her college course, had begun new part-time work and was socialising with peers in college.

Conclusion

The aim of this article was to emphasise the importance of a formulation-based approach in the treatment of complex cases as it allows for the integration of different treatment models, addressing a variety of problem presentations. Case conceptualisation and treatment focused on difficulties related to Adjustment Disorder in this case example as advised by Smith et al. (2010). CBT with exposure and response prevention was used for the initial treatment of comorbid OCD (Van Niekerk 2009; Diehle et al. 2015). However, this intervention was not successful as the impact of the past bullying continued to maintain Enid’s negative self-beliefs. Following reformulation, a narrative approach combined with parallel processing addressed and challenged Enid’s beliefs about her being unlikeable and weak, as well as her sense of responsibility. Integrating a Compassionate Focused Technique (Gilbert 2010) in this process further supported this change. Despite the effectiveness of CBT in addressing and correcting unhelpful beliefs about likeability and responsibility, Enid continued to experience strong emotions of humiliation and embarrassment associated with the bullying from the past. As mentioned by Herbert (2002), EMDR allows for a more holistic processing of all the elements associated with the traumatic experience. Based on this view, promoted by Bronner et al. (2009), it was decided to introduce EMDR as a supplement for the CBT approach employed during the first 10 sessions. This introduction allowed Enid to process her negative affect associated with the memory of her being humiliated. By first addressing her past memories related to the bullying, some of Enid’s beliefs about appearance were partially addressed during the processing of difficult memories. This allowed Enid to be better prepared and motivated for the re-introduction of exposure-based experiments (Van Niekerk 2009), consequently resulting in a speedier recovery (only five further sessions).

The purpose of this article was not to unfavourably compare and judge the two models (CBT and EMDR), but rather to focus on the potential integration of two different approaches in the treatment of a complex presentation in a young person. Both methods have specific strengths and attributes in the treatment of trauma related presentations (Diehle et al. 2014). In this case, the sessions of CBT (Van Niekerk 2009) and additional compassion- focused practices (Gilbert 2010) allowed for the reconstruction of previously held beliefs and the simultaneous addressing of comorbidity. The further introduction of EMDR assisted the client in the reprocessing of negative affect associated with a humiliating incident and strengthening the effects of compassion focused principles.

Research has suggested that there are a number of people who do not respond to common interventions such as CBT (Guzick et al. 2018), citing the need to understand the individual differences which may impact positive change, and adapt interventions accordingly. Controversy also exists about the generalisability of findings from research participants ‘handpicked’ to fit a diagnosis, to those patients seen in mental health services (Butler et al. 2008). This can cause debate within psychologists and mental health professionals about how to best assess research and treat such difficulties. Westbrook and Kirk (2005) explored the efficacy of interventions in less restrictive, more real-to-life mental health populations, rather than in studies conducted on selective groups of participants. They suggested that treatments for mental health difficulties were somewhat effective, although successful results may not be as high as research trial findings. The idea of ‘flexibility within the fidelity’ of treatment highlights that manualized or generic treatment plans may not be the most effective method for intervention, rather, that a therapist must be flexible with personalised treatment components whilst still adhering to evidence based practice (Kendall and Beidas 2007).

To conclude, the aim of the case formulation approach is to develop a framework for the provision of intervention that flexibly meets the unique needs of the young person and to guide the therapist’s decision-making (Kuyken et al. 2008). As such, this article promotes the integration of different treatment strategies within the context of a well-established case conceptualisation, using routine outcome measures to support this conclusion.

Compliance with Ethical Standards

Conflict of Interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical Standards and Informed Consent

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Footnotes

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