The Case of "Daniel": Flexibly Delivering an Inherently Challenging Treatment in the Face of a Complex Presentation

In this article, I respond to commentaries by Martin Franklin (2019) and by Liza Pincus and Andrea Quinn (2019) about my case study of "Daniel" (Tice, 2019), a 14-year-old young man presenting to therapy with Obsessive Compulsive Disorder (OCD) and Generalized Anxiety Disorder (GAD). I treated Daniel with a manual-based, 25-session treatment centered around the cognitive-behavioral approach of Exposure and Response Prevention (E/RP). A major theme running through my case study and the two commentaries is the need for flexibility in adapting the manual to be responsive to a variety of factors associated with Daniel’s disorder, such as his personality, interests, life situation, attitude towards his symptoms, and his way of relating to the therapist. In the context of the commentaries, I review a variety of the specific ways in which I learned to be flexible. Some of these included (a) focusing on nonspecific factors in developing a strong therapeutic alliance and rapport; (b) paying particular attention to how I communicated relevant psychoeducational concepts to Daniel, particularly by the use of metaphors, in preparing him for the E/RP procedures and in encouraging his participation; and (c) focusing on the process of making decisions at important clinical choice points.