After 3 months, the intake process was completed successfully, yielding the following diagnostic summary. An 18-year-old woman was referred to the treatment due to ongoing trauma, panic attacks, school dropout, and a difficult family situation. She had experienced multiple traumatic events (sexual and abusive) that have had a major influence on her self-image and image of others. Consequently, Michelle showed avoidant coping behavior in difficult situations, poor coping skills, and anger. She had to deal with several family issues at home and had gone through many changing family compositions (Figure 1). Michelle's symptoms were classified as PTSD and agoraphobia. A hypothesis about the coherence of Michelle's problems was formulated (Figure 2). Subsequently, a treatment plan that described treatment goals was drawn with Michelle (Table 3).
As part of Youth Flexible ACT involvement, baseline and follow-up outcome measures were administered to assess overall psychological distress (OQ-45) and severity of PTSD symptoms (PSS-SR). The OQ-45 is a self-report questionnaire consisting of 45 items yielding a total score and 3 subscale scores. Items were scored on a 5-point rating scale, ranging from never (0) to almost always (4). A cut-off score of 55 on the full scale indicates clinically significant distress. The PSS self-report version consists of 17 items corresponding to the PTSS symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Items were scored according to the frequency of symptom occurrence in the past week, ranging from 0 (not at all) to 3 (5 or more times per week). The PSS-SR provides a total score and three subscores. Higher scores represent more severe symptoms.
After the intake report and treatment plan had been approved, the active treatment phase could start. Multiple team members were assigned to Michelle:
A head practitioner (healthcare psychologist/skilled in systemic working) coordinated the care process, became acquainted with the family system, mapped out why previous care services failed and provided EMDR therapy;
A PNP provided support to help Michelle cope with problems in her everyday life and provided parent counseling sessions;
A social worker (also skilled in systemic working) provided Emotion Regulation Therapy (ERT) and offered support with searching and referring to community resources, such as school or job opportunities, and with conducting parent counseling sessions, and
A psychiatrist examined whether medication could be a helpful addition.
Official systemic therapy was not indicated, as team members believed therapy would not be feasible for the family due to the stressful and changing home situation. Additionally, immediate treatment for trauma and anxiety symptoms was not indicated due to Michelle's limited trust in mental healthcare workers.
During this first year, the team focused on initiating and sustaining contact with Michelle and her ex-stepfather. Gradually, the involved team members got to know her better, and Michelle started to speak freely. Michelle had gained more confidence in the care process.
Michelle explained to the PNP that she was afraid to take a shower and go to the dentist. When showering, she experienced a lot of tension because of earlier traumatic events in the bathroom. The PNP practiced exposure therapy techniques with Michelle to become less anxious to go out alone and supported her with visits to the dentist. Additionally, they started setting up a crisis and contingency plan. Meanwhile, the social worker started with ERT, and during the year, Michelle gained more insight into her emotional self-regulation. Furthermore, Michelle started taking fluoxetine to feel calmer, less panicky, and less agitated. When necessary, she also took quetiapine to suppress her unrest.
At the end of the year, Michelle managed to undertake activities by herself (go to the store, dentist, shower). She appeared calmer and indicated she would like to start trauma therapy.
With the support of the social worker, Michelle set up a resume and dared to take the step to apply for work in a department store. The social worker had arranged that Michelle could start working while she continued to receive disability benefits. Michelle was hired, and the employer was very helpful and understanding of her mental health issues. The first working days went well, and Michelle was very proud.
Psychiatric Nurse Practitioner provided psychoeducation to the ex-stepfather, Michelle's mother, and her therapist, explaining Michelle's problems and describing the ways in which her parents could support her. Michelle has managed to distance herself from the home situation during the year by focusing on the application process and work. However, the team members noticed that Michelle was still very dependent on her ex-stepfather. Although her situation had improved, she hardly ever left his side.
Together with the social worker, Michelle took steps in administrative matters, managing her financial situation.
Eye Movement Desensitization and Reprocessing therapy sessions were scheduled in the second year. The conversations with the PNP, social worker, and psychiatrist continued.
Michelle gained more insights into her avoidance pattern during the sessions with the involved team members. She understood the role of avoidant coping and distrusting others in previous (unsuccessful) treatments.
During the introductory talks with the EMDR therapist, Michelle pointed out that she had not yet reported sexual abuse to the police and wanted to do so. They decided first to file a report and subsequently start EMDR. However, when the EMDR sessions eventually started, she kept canceling the sessions. She mentioned that she had a lot on her mind concerning her home situation. Her half-sister was in a closed youth care institution, and Michelle was very worried about her. Furthermore, her mother lived temporarily with Michelle's ex-stepfather for her mother's safety. This caused a lot of stress in the family, eventually leading to Michelle's emotional outburst. Michelle took (small) overdoses of sleeping pills to suppress these emotions. The team members who were already involved were increasing the contact frequency. Other team members knew what was going on and, when necessary, could help immediately. After 2 weeks, when Michelle was calmer again, the situation was re-evaluated with Michelle and family members and with her mother's therapist. Together with the social worker, Michelle talked about her stress triggers, methods she could use to manage and reduce stress symptoms, and different ways she could ask for support.
Michelle had had a good start at work and handled her fears. She understood that she had not gained successful and positive experiences due to anxiety and avoidance, which hurt her self-image. Now, she showed perseverance. Unfortunately, after a few months, she suffered from tension headaches and experienced a lot of stress due to family issues. Michelle couldn't handle going to work, and as a result, her temporary contract was not being renewed.
Michelle, her mother, and her ex-stepfather knew that Michelle had to maintain a healthy balance between paying attention to others and doing what was good for herself. Acting on this has proven difficult. Her mother and her mothers' therapist discussed that the mother should not take responsibility for Michelle.
Michelle missed an appointment with the occupational physician, for which a fee was charged. Michelle was already stressed, and then experienced even more stress as she couldn't afford this. She told the social worker she also failed to pay her healthcare insurance. Eventually, the income and work consultant of the municipality had set up a plan through which a payment arrangement was agreed. Michelle knew she should have contacted several organizations to arrange her finances but did not do so. She found it very difficult to make the necessary phone calls, and because she felt ashamed, she postponed and avoided this. The social worker discussed and addressed this recurring avoidance tendency with Michelle.
During the third year, an IPS counselor (Individual Placement and Support) was deployed to help Michelle search for work. The EMDR sessions were continued, and the social worker still provided support and parent counseling sessions. Medication continued to be administered. The PNP was only deployed when necessary.
The EMDR sessions, during which the social worker was closely involved by driving Michelle to and from the sessions and providing aftercare during the supportive contacts, were resumed. This agreement gave Michelle a safe feeling and helped her deal with emotions in daily practice.
Michelle no longer suffered from trauma-related complaints. She had no traumatic memories, no nightmares, and she was less hyper-alert. Michelle felt less irritation and anger and dealt with her emotions more adequately. Because her level of tension decreased, she was much more daring to go out alone and less dependent on her ex-stepfather. She even got her driver's license.
Michelle was introduced to the IPS counselor, and together they set up a new work plan. A basic qualification was required to retain social assistance benefits for a good starting position in the labor market. Michelle refused to take classroom education, and given her avoidance pattern, it was not expected to be successful at this time. A home study (preparation for maternity nurse) was set up to get her used to education. The IPS counselor contacted the municipality, and they paid for the home study and laptop while retaining sickness benefits. Michelle was afraid to start with the study, but it did go well after a few days. However, after a few months, Michelle had trouble following the study. She indicated that the discussed theories were too difficult to understand and gave her a feeling of failure. Initially, Michelle wished to quit her study, but after joint meetings with the social worker, Michelle, and other relatives, she managed to catch up with the study again.
Michelle was much less irritated and more patient with her relatives. She was more successful in making choices for herself (going to therapy, studying) and stopped trying to take over someone else's problems. For example, when her mother moved to another house and called on her for help, Michelle could cope in a controlled and calm way.
At the request of Michelle, her ex-stepfather helped her manage financial matters.
During the fourth year, the spread of coronavirus caused lockdowns worldwide. In the beginning, sessions mainly took place by telephone or video calling, in the garden, or during walks. IPS, EMDR, sessions with the social worker, and medication consults were continued.
Halfway through the year, a horrible event took place. Michelle's half-sister, still a minor, went missing. Luckily, her sister returned home after 2 weeks. During this period, the team care provided additional support, and a social worker, the PNP, or head psychologist visited Michelle daily.
Because of the episode with her sister, new cases of abuse came to light that triggered trauma complaints. The EMDR sessions were resumed with images that were not treated before. The sessions went well. Michelle still experienced some anger but indicated she was no longer re-experiencing the symptoms. During the fourth year, Michelle showed much more control in handling her emotions. Despite the turmoil in her family, Michelle was more stable and started to cope better with the things she's gone through. She could handle setbacks more easily and react more calmly. Her medication (fluoxetine) was gradually reduced.
Michelle caught up with her studies but soon indicated that it took a lot of effort for her to consistently comprehend the theory and that she wanted to stop with the study. The IPS counselor listened and indicated that a work-study program suited Michelle better. Individual internal training at an organization seemed more appropriate than classroom training or home study. Together with the IPS counselor, Michelle had visited several employers, and she applied for a learn/work trajectory at a healthcare institution.
During the fourth year, Michelle developed better communication with family members and her mother and ex-stepfather did no longer involve her as much in their daily struggles. Michelle managed to maintain a healthier balance between her needs and those of others. She had more control in taking care of things for herself (i.e., reschedule an appointment, make a phone call to institutions). When Michelle's two youngest siblings came to live with her ex-stepfather, it was getting more crowded, and Michelle expressed carefully that she needed a place to live on her own. The team already had this in mind earlier but deliberately did not focus on it because they still expected resistance and avoidance at that time. The social worker helped Michelle explore other housing options.
Flexible ACT care is provided as long as necessary and as briefly as possible to achieve symptomatic, functional, and personal recovery. Whether the specialized intensive mental health care can be downgraded to primary [General Practitioner (GP), primary care psychologist, social district team] or secondary office-based mental health care is continuously monitored throughout the care period and carefully considered by taking into account symptomatic remission, complex medication use, school attendance, having a job or other form of daytime activities, availability of support systems, financial situation, confidence in the recovery, and ability to accept guidance and call for help when necessary. In addition to leaving care upon recovery, clients exit Youth Flexible ACT when they reach the age limit. When clients reach the age of 23, various forms of follow-up care are considered, depending on the situation. Exits and transfers are discussed and planned carefully with the clients and their relatives and are structured and staged. The team ensures a "smooth" transfer from old to new care providers through shared contacts to guarantee continuity of care.
Michelle recently turned 23; therefore, the Youth Flexible ACT team discussed with her the transition to AMHS in the coming year. Michelle and the team members agreed that intensive Flexible ACT care was no longer necessary While Michelle reported high scores on overall psychological distress (OQ-45) and on severity of PTSD symptom (PSS-SR) at the start of Flexible ACT, her distress and trauma symptoms decreased sufficiently at the end of Flexible ACT (Table 4). Michelle still experienced some anger after the EMDR sessions, but she was no longer suffering from re-experiencing symptoms. The communication with family members improved. She applied for a work-study program, felt more empowered, and made choices and arranged things for herself.
The final phase (phasing out) would focus on preparing for the transition to adult- and primary care, maintaining the progress achieved, and preventing Michelle from reverting to negative behavior. Setting up a relapse prevention plan, which describes triggers, coping tools, and support group information is always an important part of this final phase. The following interventions were included in the final treatment plan of Michelle: setting up a relapse prevention plan, continuing IPS counseling, transferring medication to a general practitioner, contacting mother's therapist, contacting involved social services, and becoming acquainted with a new mental health care provider. The IPS trajectory could be continued without Flexible ACT.