- Email: [email protected]
Awareness training in the treatment of head and facial tics
AWARENESS
TRAINING IN THE TREATMENT HEAD AND FACIAL TICS KATHLEEN
OF
M. WRIGHT
Georgia Southern
College
and
RAYMOND
G. MILTENBERGER
i\;orth Dakota
State University
Summary-The effectiveness of awareness training alow in treating multiple tics in a young adult was assessed using a multiple baseline across behaviors design. The results showed that the awareness training was very effective in suppressing both head and facial tics and that the trcatmcnt cffect5 gcncralircd to ;I nonclinic situation. Follou--up data ~howcd that both tics wcrc Still at low Ievcls enc. two. four and eivht month\ .Iftcr trcatmcnt. Treatment satisfaction ratings by the subJcct and social validatwn ratings by indcpcndcnt ohwrverb arc i&o rcportcil. L__
Muscle tics, defined as contractions of functionally related groups of skeletal muscles in one or more parts of the body (Bird ef uf., 19Sl; Shapiro et al., 197s; Singer, 19%) have been estimated to occur in approximately 1% of the population (Azrin and Nunn, 1973). Although a number of behavioral procedures have been used to treat tics, the habit reversal treatment procedure developed by Azrin and Nunn (1973) has been demonstrated to be one of the most effective (Azrin et ul., 19SO; Finney ef ul.. 1953; Miltenberger el al., 19S5; Rosenbaum and Ayllon, 1981). While habit reversal is a multicomponent treatment package, it appears that one component, the use of a competing response, may be the most critical in determining treatment success (Miltenberger et al., 1985; Ollendick, 1981). The competing response procedure requires the subject to identify each tic occurrence and engage in a physically incompatible competing response for 3 min. It is therefore open to question whether the competing response is a necessary part of the treatment procedure or Requests for reprints should be sent to Kathleen Statesboro. GA 30458, U.S.A.
Wright,
269
whether the increase in awareness may serve to decrease the frequency of the tic by itself. Self-monitoring, a procedure which increases the subject’s awareness of the occurrence of the muscle tic, has been evaluated as a treatment procedure in a few studies (Billings, 1978; Ollendick. 1951; Thomas et al., 1971). Thomas et al. (1971) found that self-monitoring was effective in decreasing three tics in an IS-year-old male diagnosed as having Gilles de la Tourette syndrome. However, the effect of the self-monitoring was confounded with the effects of praise for decreased tic rates, relaxation training, imaginal and in viva desensitization, and haloperidol. With two young children serving as subjects, Ollendick (1981) found that self-monitoring alone was effective with one subject but the other required competing response training. He hypothesized that the self-monitoring was effective with the one boy because his tic was of shorter duration and thus less resistant to change. And finally, using a multiple baseline across behaviors design, Billings (1981) found self-monitoring Ph.D.,
Psychology
Dept.
Georgia
Southern
College,
2m
KATHLEEN
\I. U’RIGHT
and R;\Y.LIOND
effective in reducing tvvo tics in a young woman. Billings’ findings, horvsv,er. must be interpreted with caution because only selfreport data were collected on the tic frequencies. The purpose of this study was to evaluate the effectiveness of awareness training in treating a young man’s multiple tics. The experiment added to previous studies through the use of direct observation data collection, a multiple baseline across behaviors design, and the assessment of generalization to a nonclinic situation. In addition, treatment satisfaction ratings, and social validation ratings of treatment outcome were collected.
METHOD Subject Steven, a 19-year-old college student, sought treatment for muscle tics involving head movements and excessive eyebrow raising. He reported that the tics were annoying to him and conspicuous to other people who, at times, mentioned the tics to him. Steven found these two tics especially bothersome because he felt that they would decrease his chances of success in a broadcasting career. He reported that he was aware of approximately 90% of the occurrences of both tics and that each tic occurred with a roughly equal frequency of about 20 times per day. Steven estimated that he had been engaging in the tics without any periods of cessation since about age 13 and he could not recall any events associated with their onset. He reported no psychological or medical problems that may h,ave been related to the tics. He was an otherwise well-adjusted and typical college student. Previous attempts to stop the tics involved -*trying to relax” although he had not sought professional help. Setting Clinic sessions were conducted in a 2.2 x 3.3 m room which contained videotape equipment and two chairs. Except during awareness training sessions, the door was kept closed and
G
\lILTENBERGER
Steven was alone in the room. Generalization sessions took place in various locations in the college librarv Dutu collectiotl The duration of each observation session was 25 min. during which time Steven sat in the chair in front of the camera and read a testbook or a newspaper. Data were recorded on a 13 s partial interval scoring system. Thr three graduate students who semed as observers were trained for three hours \vith instruction, rehearsal and feedback using videotapes of the subject in initial sessions. Instances of the head movement tic were defined as any upward movement. stretching of the neck to the side, or jerk to the side. The definition of the eyebrow tic was any upward movement of one or both eyebrows from a previous level. The library . 22 ~7eneralization sessions were also 75 min long. During these sessions, the observer(s) sat approximately 7.5 m from Steven while he studied in a lounge chair. The tape of each scoring interval was quietly played on a tape recorder at a level inaudible to Steven. When reliability data were collected in the library, that observers sat about 0.8 m apart. Cotuutt~er satisfaction. At the end of the last observation session Stev,en filled out a consumer satisfaction questionnaire. He vvas to rate, on a j-point Likert scale, how much the tics distressed him and how much they were noticeable to others before and after treatment. He was also asked to rate his satisfaction with the treatment procedure. Social validatiotz. Tw.0 baseline and two post-treatment videotapes were randomly selected and were shown in a random order to four independent observers who had not previously participated in the study. They rated the tics on their distractability. normality. and magnitude. After being told which videotapes were the post-treatment videotapes they were asked how satisfied they would be if they achieved the same results as Steven had.
Interobserver
agreement
Sixty-one per cent of the videotapes during baseline and 30% of the videotapes in each remaining phase were randomly selected and scored by an independent observer. Two independent observers collected data during 75% of library generalization sessions. Agreement uas calculated by dividing the number of agreements on occurrence and nonoccurrence by the total number of intervals scored. The mean per cent agreement for the head movement tic during clinic observations was 90% with a range of 57-98”:;. For the eyebrow tic the mean per cent agreement in the clinic was S6% with a range of N-91%. During library sessions, the average per cent agreement was 95% for the head tic (range S7-99%) and 93% for the eyebrow tic (range M--9S%).
Procedure E.rperirnental
desigtl. The degree to which awareness training would lead to a reduction in the frequency of the tvvo tics was evaluated by using a multiple baseline across behaviors experimental design (Barlow and Hersen, 1984). Treatment was providod first for the head tic and subsequently for the eyebrow tic. Baseline. During the baseline period, clinic observation sessions occurred 2-5 days per week. In addition, three library generalization sessions were conducted. During the baseline observation phase Steven was told not to attempt to alter the occurrence of the tics in any way. Treatment. In the first treatment session Steven was provided with a rationale for the use of awareness training. The experimenter explained that the tic occurred without his awareness and that increased awareness would help decrease or eliminate the tic. Following this rationale Steven memorized a written description of the movements involved in the tic. Once he could reliably describe this he was asked to demonstrate each of the head movement topographies (i.e. a lift, a stretch and a
jerk). The remainder of the session involved practice identifying each occurrence of the tic for 31 min. The experimenter sat across the room from him and instructed Steven to say ‘-head” each time the head movement tic occurred. If he did not identify a tic occurrence within 2 s. the experimenter prompted him. Before leaving the session Steven was instructed to record each instance of the head tic immediately after its occurrence on an index card throughout the day. He was told the purpose of the self-recording was to heighten awareness of the tic, and that he should continue self recording for the duration of the study. Ten additional awareness training sessions for the head tic averaging 21 min each (range 10-50 min) were conducted over 5 weeks. Session duration was variable due to the amount of time the subject had available for sessions. Prior to each session Steven was videotaped for assessment of the tics. Each training session involved practice identifying tic occurrences. To enhance his ability to discriminate each occurrence of the tic during the 7th and 9th sessions the experimenter had Steven watch a videotape of himself and identify each tic occurrence from the tape. (His eyes were occluded on the tape so the eyebrow tic frequency would not be influenced.) To further enhance his discrimination of tic occurrences Steven imagined stressful scenes in the 8th session. Once the frequency of the head tic had stabilized at a low level, awareness training was introduced with the eyebrow tic. Six training sessions, averaging 33 min with a range of 15-45 min. were conducted. The procedure was similar to that used for the head tic except that Steven watched his ongoing behavior on a television screen during at least 10 min of five sessions. Follow-up. Steven returned for follow-up assessment sessions one, two, and four months after the last session. At each of these followan observation session was UP sessions.
272
videotaped frequency
KATHLEEti
$1. ‘KRIGHT
and RXY\lOSD
and Steven 1va.s asksd about the of the tics throughout the day.
and 4% after treatment. For the eyebrow tic. the average per cent of intervals scored was 42”L during baseline and 3?L after treatment. As in the clinic sessions. there was some decrease in the eyebrow tic when the awareness training was implemented on the head tic, a decrease from 17% of intenals scored to 36%. Furthermore. Fig. 1 sho\vs that there was maintenance of treatment effects across time. At the one-month follow-up both tics occurred during 3% of intervals scored. The head tic remained at this low level after eight months. The eyebrow tic increased slightly to 13% after two months and to 17% after four months. but decreased to S% after eight months. Beginning with the first training session the majority of head tics that occurred during training sessions were of much smaller magnitude than those that occurred during baseline assessment sessions and the frequency of the tics dropped to low levels. Steven only identified 1 of the 50 head movements that occurred in the 11 training sessions. Imagining stressful scenes during training sessions did not increase the tic frequency nor improve his discrimination of tic occurrences. During the last 8 training sessions Steven was not identifying any of the tics that were occurring. HoLvever. after the 6th session only one head movement occurred per lo-min period on the average. As
RESULTS As shown in Fig. 1. the awareness trainins had a clear effect when it was implemented uith each tic. The average per cent of intervals scored with an occurrence of the head tic was 53% (range 31-799/b) during baseline and 15% after treatment (range %-4-l%). For the eyebrow tic. the average per cent of intervals scored was 57% (range 1943%) during baseline and 15% after awareness training (range 3-29%). It is clear from Fig. 1 that the eyebrow tic decreased in frequency when treatment was implemented for the head tic. Prior to awareness training for the head tic the mean level of the eyebrow tic was 64% (range 42-77%). After intervention on the head tic. but before intervention kvith the eyebrow tic. the mean level dropped to 49% of intervals (range 1943%). However, the treatment for the eyebrow tic further decreased its frequency to very low levels. Figure 1 also shows that the data on both tics during the generalization sessions correspond very well to the data obtained in the clinic setting. The average per cent of intervals scored on the head tic was 18% during baseline
Awreness
, /
G. XIILTESBERGER
trainrq l
Cllnlc
0
Generallzatlon
sess1an5
sessloffi
I30 60 40 20 0 5
IO
I5
Sessions Fig. 1. Per cent of 12 s intervals
phases.
20
25
30
I246
(months)
of the two IICS in clinic and nonclinic obsrrvation
xssions :lcross brtsrlins
and treatment
AWARENESS
TRAINING
with the head tic Steven had difficulty identifying occurrences of the eyebrow tic and the magnitude of most responses was very small relative to baseline. He identified 15% of the eyebrow raises that occurred during training sessions. In the last training session, which lasted 40 min. Steven did not identify any of the 9 eyebrow raises that occurred. Steven’s responses on the treatment satisfaction questionnaire showed that he was no longer distressed by the tics and that he felt they were no longer very noticeable to other people. He rated his overall satisfaction with the treatment procedure as a 5 (very satisfied). On the social validation questionnaire the observers rated the tics on the baseline tapes as being more distracting, less ‘normal”, and of greater magnitude than the tics on the treatment tapes even though the observers were not told before they gave their ratings which tapes were from baseline and which were from treatment. From the treatment tapes the subject’s tics were rated as not at all distracting, normal to very normal in appearance, and small to very small in magnitude. In addition, all observers reported that they would have been satisfied with the treatment results.
DISCUSSION The results showed that awareness training alone was very effective in decreasing muscle tics that had been occurring over approximately a &year period for this subject. Although some generalization of treatment effects from the head tic to the eyebrow tic was seen, clear experimental control by the training procedure was demonstrated for both tics. In addition, generalization to a nonclinic setting and maintenance of treatment effects were demonstrated. Social validation results also showed that the treatment effects resulted in an important change in Steven’s behavior. Not only did the awareness training decrease the frequency of the tics, it also decreased their magnitude to the point that they were barely
WITH
TICS
273
noticeable by an observer. The low response rate and small magnitude of the tics may have been responsible for Steven’s inability to learn to identify instances of the tics during training sessions. And, since the subject could not reliably detect the occurrence of the tics, the mechanism responsible for the effectiveness of awareness training remains unclear. Upon questioning. Steven could not identify any other self control strategy that he consciously used that may have contributed to the success of awareness training. One can speculate that the effect of “awareness training” was not to increase a conscious awareness of the tic such that the subject could verbally identify its occurrence, but rather, to make the occurrence of the tic an aversive event (because of unspecifiable therapist evaluations or demand characteristics). Any behavior that functions to terminate or avoid the tic occurrence was therefore negatively reinforced. According to this view, the client was not aware of tic occurrence in the typical sense but unconsciously acted to prevent its occurrence without awareness of the process. Despite procedural differences it is possible that the same negative learning was at work in this treatment as in the treatment of tics described by Taylor (1963). Steven’s inability to identify his tics in a controlled clinic setting seriously brings into question the validity of self-report data with muscle tics. Researchers and clinicians working with tic disorders should be cautious about accepting self-report as their primary data. If self-report are the only available data robust reliability measures should also be required. Although it was shown to be effective with both tics for this client, one potential concern about the use of awareness training to treat muscle tics is that the treatment procedure may not seem sophisticated enough to some clients, especially those expecting complex or timeconsuming procedures. On the other hand, the simplicity of the procedure may appeal to some people, as it did to the client in this study. In
171
KXTHLEEX
ht.
WRIGHT
and
case. it seems the credibility of the treatment rationale would be ;1 crucial factor in treatment acceptability and ultimately in the treatment’s success. In summary. the results sho\ved that. at least for this individual. awareness training alone LVilS sufficient in decreasing muscle tics. Further research should involve replication across many subjects with tics and direct comparison with the competing response procedure. Further research might also investigate why the alvareness training procedure is effective in the reduction of tics. In addition, evaluation of the procedure with more severe tics associated with Tourette syndrome should be conducted. Finally, the acceptability of such a simple treatment procedure for those who suffer from muscle tics needs to be further investigated. any
RAY\IOND
G.
\IILTEZBERGER
TRAINING IN THE TREATMENT HEAD AND FACIAL TICS KATHLEEN
OF
M. WRIGHT
Georgia Southern
College
and
RAYMOND
G. MILTENBERGER
i\;orth Dakota
State University
Summary-The effectiveness of awareness training alow in treating multiple tics in a young adult was assessed using a multiple baseline across behaviors design. The results showed that the awareness training was very effective in suppressing both head and facial tics and that the trcatmcnt cffect5 gcncralircd to ;I nonclinic situation. Follou--up data ~howcd that both tics wcrc Still at low Ievcls enc. two. four and eivht month\ .Iftcr trcatmcnt. Treatment satisfaction ratings by the subJcct and social validatwn ratings by indcpcndcnt ohwrverb arc i&o rcportcil. L__
Muscle tics, defined as contractions of functionally related groups of skeletal muscles in one or more parts of the body (Bird ef uf., 19Sl; Shapiro et al., 197s; Singer, 19%) have been estimated to occur in approximately 1% of the population (Azrin and Nunn, 1973). Although a number of behavioral procedures have been used to treat tics, the habit reversal treatment procedure developed by Azrin and Nunn (1973) has been demonstrated to be one of the most effective (Azrin et ul., 19SO; Finney ef ul.. 1953; Miltenberger el al., 19S5; Rosenbaum and Ayllon, 1981). While habit reversal is a multicomponent treatment package, it appears that one component, the use of a competing response, may be the most critical in determining treatment success (Miltenberger et al., 1985; Ollendick, 1981). The competing response procedure requires the subject to identify each tic occurrence and engage in a physically incompatible competing response for 3 min. It is therefore open to question whether the competing response is a necessary part of the treatment procedure or Requests for reprints should be sent to Kathleen Statesboro. GA 30458, U.S.A.
Wright,
269
whether the increase in awareness may serve to decrease the frequency of the tic by itself. Self-monitoring, a procedure which increases the subject’s awareness of the occurrence of the muscle tic, has been evaluated as a treatment procedure in a few studies (Billings, 1978; Ollendick. 1951; Thomas et al., 1971). Thomas et al. (1971) found that self-monitoring was effective in decreasing three tics in an IS-year-old male diagnosed as having Gilles de la Tourette syndrome. However, the effect of the self-monitoring was confounded with the effects of praise for decreased tic rates, relaxation training, imaginal and in viva desensitization, and haloperidol. With two young children serving as subjects, Ollendick (1981) found that self-monitoring alone was effective with one subject but the other required competing response training. He hypothesized that the self-monitoring was effective with the one boy because his tic was of shorter duration and thus less resistant to change. And finally, using a multiple baseline across behaviors design, Billings (1981) found self-monitoring Ph.D.,
Psychology
Dept.
Georgia
Southern
College,
2m
KATHLEEN
\I. U’RIGHT
and R;\Y.LIOND
effective in reducing tvvo tics in a young woman. Billings’ findings, horvsv,er. must be interpreted with caution because only selfreport data were collected on the tic frequencies. The purpose of this study was to evaluate the effectiveness of awareness training in treating a young man’s multiple tics. The experiment added to previous studies through the use of direct observation data collection, a multiple baseline across behaviors design, and the assessment of generalization to a nonclinic situation. In addition, treatment satisfaction ratings, and social validation ratings of treatment outcome were collected.
METHOD Subject Steven, a 19-year-old college student, sought treatment for muscle tics involving head movements and excessive eyebrow raising. He reported that the tics were annoying to him and conspicuous to other people who, at times, mentioned the tics to him. Steven found these two tics especially bothersome because he felt that they would decrease his chances of success in a broadcasting career. He reported that he was aware of approximately 90% of the occurrences of both tics and that each tic occurred with a roughly equal frequency of about 20 times per day. Steven estimated that he had been engaging in the tics without any periods of cessation since about age 13 and he could not recall any events associated with their onset. He reported no psychological or medical problems that may h,ave been related to the tics. He was an otherwise well-adjusted and typical college student. Previous attempts to stop the tics involved -*trying to relax” although he had not sought professional help. Setting Clinic sessions were conducted in a 2.2 x 3.3 m room which contained videotape equipment and two chairs. Except during awareness training sessions, the door was kept closed and
G
\lILTENBERGER
Steven was alone in the room. Generalization sessions took place in various locations in the college librarv Dutu collectiotl The duration of each observation session was 25 min. during which time Steven sat in the chair in front of the camera and read a testbook or a newspaper. Data were recorded on a 13 s partial interval scoring system. Thr three graduate students who semed as observers were trained for three hours \vith instruction, rehearsal and feedback using videotapes of the subject in initial sessions. Instances of the head movement tic were defined as any upward movement. stretching of the neck to the side, or jerk to the side. The definition of the eyebrow tic was any upward movement of one or both eyebrows from a previous level. The library . 22 ~7eneralization sessions were also 75 min long. During these sessions, the observer(s) sat approximately 7.5 m from Steven while he studied in a lounge chair. The tape of each scoring interval was quietly played on a tape recorder at a level inaudible to Steven. When reliability data were collected in the library, that observers sat about 0.8 m apart. Cotuutt~er satisfaction. At the end of the last observation session Stev,en filled out a consumer satisfaction questionnaire. He vvas to rate, on a j-point Likert scale, how much the tics distressed him and how much they were noticeable to others before and after treatment. He was also asked to rate his satisfaction with the treatment procedure. Social validatiotz. Tw.0 baseline and two post-treatment videotapes were randomly selected and were shown in a random order to four independent observers who had not previously participated in the study. They rated the tics on their distractability. normality. and magnitude. After being told which videotapes were the post-treatment videotapes they were asked how satisfied they would be if they achieved the same results as Steven had.
Interobserver
agreement
Sixty-one per cent of the videotapes during baseline and 30% of the videotapes in each remaining phase were randomly selected and scored by an independent observer. Two independent observers collected data during 75% of library generalization sessions. Agreement uas calculated by dividing the number of agreements on occurrence and nonoccurrence by the total number of intervals scored. The mean per cent agreement for the head movement tic during clinic observations was 90% with a range of 57-98”:;. For the eyebrow tic the mean per cent agreement in the clinic was S6% with a range of N-91%. During library sessions, the average per cent agreement was 95% for the head tic (range S7-99%) and 93% for the eyebrow tic (range M--9S%).
Procedure E.rperirnental
desigtl. The degree to which awareness training would lead to a reduction in the frequency of the tvvo tics was evaluated by using a multiple baseline across behaviors experimental design (Barlow and Hersen, 1984). Treatment was providod first for the head tic and subsequently for the eyebrow tic. Baseline. During the baseline period, clinic observation sessions occurred 2-5 days per week. In addition, three library generalization sessions were conducted. During the baseline observation phase Steven was told not to attempt to alter the occurrence of the tics in any way. Treatment. In the first treatment session Steven was provided with a rationale for the use of awareness training. The experimenter explained that the tic occurred without his awareness and that increased awareness would help decrease or eliminate the tic. Following this rationale Steven memorized a written description of the movements involved in the tic. Once he could reliably describe this he was asked to demonstrate each of the head movement topographies (i.e. a lift, a stretch and a
jerk). The remainder of the session involved practice identifying each occurrence of the tic for 31 min. The experimenter sat across the room from him and instructed Steven to say ‘-head” each time the head movement tic occurred. If he did not identify a tic occurrence within 2 s. the experimenter prompted him. Before leaving the session Steven was instructed to record each instance of the head tic immediately after its occurrence on an index card throughout the day. He was told the purpose of the self-recording was to heighten awareness of the tic, and that he should continue self recording for the duration of the study. Ten additional awareness training sessions for the head tic averaging 21 min each (range 10-50 min) were conducted over 5 weeks. Session duration was variable due to the amount of time the subject had available for sessions. Prior to each session Steven was videotaped for assessment of the tics. Each training session involved practice identifying tic occurrences. To enhance his ability to discriminate each occurrence of the tic during the 7th and 9th sessions the experimenter had Steven watch a videotape of himself and identify each tic occurrence from the tape. (His eyes were occluded on the tape so the eyebrow tic frequency would not be influenced.) To further enhance his discrimination of tic occurrences Steven imagined stressful scenes in the 8th session. Once the frequency of the head tic had stabilized at a low level, awareness training was introduced with the eyebrow tic. Six training sessions, averaging 33 min with a range of 15-45 min. were conducted. The procedure was similar to that used for the head tic except that Steven watched his ongoing behavior on a television screen during at least 10 min of five sessions. Follow-up. Steven returned for follow-up assessment sessions one, two, and four months after the last session. At each of these followan observation session was UP sessions.
272
videotaped frequency
KATHLEEti
$1. ‘KRIGHT
and RXY\lOSD
and Steven 1va.s asksd about the of the tics throughout the day.
and 4% after treatment. For the eyebrow tic. the average per cent of intervals scored was 42”L during baseline and 3?L after treatment. As in the clinic sessions. there was some decrease in the eyebrow tic when the awareness training was implemented on the head tic, a decrease from 17% of intenals scored to 36%. Furthermore. Fig. 1 sho\vs that there was maintenance of treatment effects across time. At the one-month follow-up both tics occurred during 3% of intervals scored. The head tic remained at this low level after eight months. The eyebrow tic increased slightly to 13% after two months and to 17% after four months. but decreased to S% after eight months. Beginning with the first training session the majority of head tics that occurred during training sessions were of much smaller magnitude than those that occurred during baseline assessment sessions and the frequency of the tics dropped to low levels. Steven only identified 1 of the 50 head movements that occurred in the 11 training sessions. Imagining stressful scenes during training sessions did not increase the tic frequency nor improve his discrimination of tic occurrences. During the last 8 training sessions Steven was not identifying any of the tics that were occurring. HoLvever. after the 6th session only one head movement occurred per lo-min period on the average. As
RESULTS As shown in Fig. 1. the awareness trainins had a clear effect when it was implemented uith each tic. The average per cent of intervals scored with an occurrence of the head tic was 53% (range 31-799/b) during baseline and 15% after treatment (range %-4-l%). For the eyebrow tic. the average per cent of intervals scored was 57% (range 1943%) during baseline and 15% after awareness training (range 3-29%). It is clear from Fig. 1 that the eyebrow tic decreased in frequency when treatment was implemented for the head tic. Prior to awareness training for the head tic the mean level of the eyebrow tic was 64% (range 42-77%). After intervention on the head tic. but before intervention kvith the eyebrow tic. the mean level dropped to 49% of intervals (range 1943%). However, the treatment for the eyebrow tic further decreased its frequency to very low levels. Figure 1 also shows that the data on both tics during the generalization sessions correspond very well to the data obtained in the clinic setting. The average per cent of intervals scored on the head tic was 18% during baseline
Awreness
, /
G. XIILTESBERGER
trainrq l
Cllnlc
0
Generallzatlon
sess1an5
sessloffi
I30 60 40 20 0 5
IO
I5
Sessions Fig. 1. Per cent of 12 s intervals
phases.
20
25
30
I246
(months)
of the two IICS in clinic and nonclinic obsrrvation
xssions :lcross brtsrlins
and treatment
AWARENESS
TRAINING
with the head tic Steven had difficulty identifying occurrences of the eyebrow tic and the magnitude of most responses was very small relative to baseline. He identified 15% of the eyebrow raises that occurred during training sessions. In the last training session, which lasted 40 min. Steven did not identify any of the 9 eyebrow raises that occurred. Steven’s responses on the treatment satisfaction questionnaire showed that he was no longer distressed by the tics and that he felt they were no longer very noticeable to other people. He rated his overall satisfaction with the treatment procedure as a 5 (very satisfied). On the social validation questionnaire the observers rated the tics on the baseline tapes as being more distracting, less ‘normal”, and of greater magnitude than the tics on the treatment tapes even though the observers were not told before they gave their ratings which tapes were from baseline and which were from treatment. From the treatment tapes the subject’s tics were rated as not at all distracting, normal to very normal in appearance, and small to very small in magnitude. In addition, all observers reported that they would have been satisfied with the treatment results.
DISCUSSION The results showed that awareness training alone was very effective in decreasing muscle tics that had been occurring over approximately a &year period for this subject. Although some generalization of treatment effects from the head tic to the eyebrow tic was seen, clear experimental control by the training procedure was demonstrated for both tics. In addition, generalization to a nonclinic setting and maintenance of treatment effects were demonstrated. Social validation results also showed that the treatment effects resulted in an important change in Steven’s behavior. Not only did the awareness training decrease the frequency of the tics, it also decreased their magnitude to the point that they were barely
WITH
TICS
273
noticeable by an observer. The low response rate and small magnitude of the tics may have been responsible for Steven’s inability to learn to identify instances of the tics during training sessions. And, since the subject could not reliably detect the occurrence of the tics, the mechanism responsible for the effectiveness of awareness training remains unclear. Upon questioning. Steven could not identify any other self control strategy that he consciously used that may have contributed to the success of awareness training. One can speculate that the effect of “awareness training” was not to increase a conscious awareness of the tic such that the subject could verbally identify its occurrence, but rather, to make the occurrence of the tic an aversive event (because of unspecifiable therapist evaluations or demand characteristics). Any behavior that functions to terminate or avoid the tic occurrence was therefore negatively reinforced. According to this view, the client was not aware of tic occurrence in the typical sense but unconsciously acted to prevent its occurrence without awareness of the process. Despite procedural differences it is possible that the same negative learning was at work in this treatment as in the treatment of tics described by Taylor (1963). Steven’s inability to identify his tics in a controlled clinic setting seriously brings into question the validity of self-report data with muscle tics. Researchers and clinicians working with tic disorders should be cautious about accepting self-report as their primary data. If self-report are the only available data robust reliability measures should also be required. Although it was shown to be effective with both tics for this client, one potential concern about the use of awareness training to treat muscle tics is that the treatment procedure may not seem sophisticated enough to some clients, especially those expecting complex or timeconsuming procedures. On the other hand, the simplicity of the procedure may appeal to some people, as it did to the client in this study. In
171
KXTHLEEX
ht.
WRIGHT
and
case. it seems the credibility of the treatment rationale would be ;1 crucial factor in treatment acceptability and ultimately in the treatment’s success. In summary. the results sho\ved that. at least for this individual. awareness training alone LVilS sufficient in decreasing muscle tics. Further research should involve replication across many subjects with tics and direct comparison with the competing response procedure. Further research might also investigate why the alvareness training procedure is effective in the reduction of tics. In addition, evaluation of the procedure with more severe tics associated with Tourette syndrome should be conducted. Finally, the acceptability of such a simple treatment procedure for those who suffer from muscle tics needs to be further investigated. any
RAY\IOND
G.
\IILTEZBERGER