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Self-control treatment of an eye blink tic
277
LETTERS TO THE EDITOR
reach agreements about the problem behavior, the pleasing replacement behavior, and a contingent reward. Using the game, families write as many as eleven contracts during training. (d) Objective: Practice contract compliance. Two contracts written by family members are carried out by the family during training weeks until each contract is 70% successful. When necessary, the contract is renegotiated with the game. Other contracts written during training are stored to be carried out after training ends. The last procedure seems to slow down short-term gain in order to facilitate long-term gain family members must learn that patient chipping away at their problems brings a steady reliable flow of small successes. Long-term results of family problem solving training are now being gathered. The balance of power between parents and adolescents differs from that between parents and younger children. The objectives we believe necessary for the success of parentadolescent contingency contracting assume that the nonreciprocal parent training model is inappropriate. The lessened dependency of adolescents upon parents must be taken into account to heighten commitment and compliance. A contractual approach can be used as a method of providing adolescents with a prosocial and desirable method of asserting themselves at home.
REFERENCE NOTES 1. Blechman, E. A., & Turner, A. J. Training and maintenance of family problem-solving: Component objectives and procedures. Unpublished manuscript, Yale University, 1975'. 2. Weiss, R. L., Hops, H., & Patterson, G. R. A framework for conceptualizing marital conflict, a technology for altering it, some data for evaluating it. Paper presented at the Fourth Annual International Conference on Behavior Modification, Banff, Alberta, Canada, 1972.
REFERENCES Alexander, J. F., & Parsons, B. V. Short-term behavioral intervention with delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology, 1973, 51, 219-233. Blechman, E. A. The family contract game: A tool to teach interpersonal problem solving. Family Coordinator, 1974, July, 269-281. Blechman, E. A., Olson, D. H. L., & Hellman, I. D. Stimulus control over family problemsolving behavior. Behavior Therapy, 1976, 7, 686-692. Weathers, L., & Liberman, R. P. Contingency contracting with families of delinquent adolescents. Behavior Therapy, 1975, 6, 356-366. E L A I N E A . BLECHMAN
Yale University School of Medicine 904 Howard Avenue, Ste. 2C New Haven, CT 06519 RECEIVED: May 2, 1976
Self-Control Treatment of an Eye Blink Tic To the behavior therapist, tics are behaviors with unusual sources of strength, but behaviors which are explained and treated by learning theory derived techniques, such as operant treatment procedures or mass practice procedures (Schaefer & Martin, 1969; Barrett, 1962; Schulman, 1974; Yates, 1958). Most operant treatment procedures used to
BEHAVIOR THERAPY 8 (1977) Copyright@ 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin~anyformreserved.
ISSN 0005-7894
278
LETTERS
TO
THE
EDITOR
treat tics are externally Controlled, and mass practice procedures might appear paradoxical and be difficult for the patient to accept as a viable treatment method. Azrin and Nunn (1973) reported successful habit reversal methods in eliminating such habits and tics as head jerking, lisping, nail biting, and thumb sucking. Their procedures emphasize early detection of tic onset and use focally antagonistic muscle responses in eliminating the tic. Such methods are clearly within the sphere of the client's control and appear to be treatments of choice for such disorders, The following treatment, used to treat an eye-blink tic and similar to Azrin and Nunn's (1973) habit reversal method, is another demonstration of the effectiveness of behavioral treatment in which the patient has direct control over a seemingly uncontrollable response. The patient, a 28-year-old truck mechanic with no former psychiatric history, complained of blinking uncontrollably for the preceding 4 months. The tic was interspersed with bursts of rapid blinking and brief periods of normal blinking, i.e., one blink per 5 sec. By the time he was seen he was unable to work, read, or drive his car. A medical examination had ruled out a physiological basis and pharmacological interventions were refractory. He had also rejected surgical intervention due to a high risk of facial paralysis. He was unable to identify precipitants for the tic. A behavioral analysis indicated the uncontrollable blinking to be present during the patient's waking hours, except during sexual intercourse. An average frequency of 94 blinks per minute were observed in the office during a nonintrusive baseline frequency count. A behavioral explanation of the tic was given: He was told that the tic had become a learned response which had obtained its maximum habit strength as the result of some undetermined stimulus, e.g., stress at work, but that voluntary control of his eye blinking could be learned through therapy. The treatment was labeled "extended practice of eye blink control." The procedure consisted of having the patient stare at selected objects in the office without blinking while the therapist counted out 3 sec. Following the count of three the patient was instructed to blink once. This procedure was practiced during the first and last 10 min of each session. During the fourth and subsequent treatment sessions the patient assumed the counting responsibilities while staring at objects in the room. Additionally, during the fourth session he was instructed to count to five before blinking and to subvocalize the counting. Concurrently, because the patient claimed to be tense, muscle relaxation training was initiated in the office, and a relaxation tape was made available for home use. He was instructed to practice relaxation and eye-blink control twice daily for 10 rain. Because the behavior analysis indicated his wife's attention to be often contingent upon the uncontrolled blinking, his wife agreed to make hugs and kisses contingent on the home relaxation and eye-blink control practice. By the sixth session the patient and his wife reported that he had gained complete voluntary control over the blinking and no evidence of the tic was observed during treatment. Eye-blink control practice was maintained until treatment was terminated after the eleventh session. During the seventh session some instruction in assertion training was provided in response to the patient's complaint of feeling inhibited in certain interpersonal situations. Four months after terminating treatment, the patient called to report that he had started to blink uncontrollably on several occasions. He was instructed over the telephone to start the eye-blink control practice on a daily basis until the blink was again under his voluntary control. If the problem persisted he was told to recontact the therapist. Nine months later the patient was contacted by telephone and reported that the uncontrolled eye blinking had ceased following the brief reintroduction of eye blink practice, and that he had been free of the tic during the subsequent 9 months. The introduction of the eye-blink control practice resulted in immediate decrease in the frequency of uncontrolled eye blinks and total control within six treatment sessions. AI-
BEHAVIOR T H E R A P Y 8 (1977) Copyright ~) 1977 by the Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
ISSN 0~5-7894
279
LETTERS TO THE EDITOR
though this is a single case report with its obvious generalization problems, the specific procedure employed appeared to be highly effective and reinforcing to the patient. This procedure, as well as the Azrin and Nunn's habit reversal procedures, appears to fall within a self-control model and permits the behavior therapist to be effective without assuming control for the patient's behavior.
REFERENCES Azrin, N. H., & Nunn, R. G. Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 1973, 2, 619-629. Barrett, B. N. Reductions in the rate of multiple tics by free operant conditioning methods. Journal of Nervous and Mental Disease, 1962, 135, 187-195. Schaefer, H. H., & Martin, P. L. Behavior therapy. New York: McGraw-Hill, 1969. Schulman, M. Control of tics by maternal reinforcement. Journal of Behavior Therapy and Experimental Psychiatry, 1974, 5, 95-96. Yates, A. J. The application of learning theory to the treatment of tics. Journal of Abnormal and Social Psychology, 1958, 56, 175-182. STEVEN BECK A L S. FEDORAVICIUS
Department of Psychiatry College of Medicine University of Cincinnati Cincinnati, OH 45267 RECEIVED: January 6, 1976
Social Skills Game: A General Method for the Modeling and Practice of Adaptive Behaviors A social skills training program for institutionalized assaultive patients should provide them with the opportunity to make critical judgments of appropriate and inappropriate social behaviors and observe how others judge them, as well as to practice these behaviors and receive feedback on their efforts. The program should be individualized and easy for staff to run. In addition, it should be fun for the patients to participate in and have as few "therapeutic" connotations as possible. As in any behaviorally oriented approach, any reinforcement derived from program participation should be contingent upon the patient's success in acquiring the desirable behaviors. Success in the program should not depend on the patient possessing average or superior verbal abilities. Reinforcement should be provided for cooperative behavior. The program should be focused on the acquisition of the target behaviors and not on an individual's discussions of his criminal exploits or current suspicions. Lastly, the program should lend itself to objective evaluation of patient progress. We believe that the Social Skills game described below has all of these desirable features. First, we will describe the game and then we will discuss how the game fulfills the criteria outlined above.
We wish to thank Cary Steinman for helping us with the design of the game. This research was supported by Grant 536-75A from the Ontario Mental Health Foundation.
BEHAVIOR T H E R A P Y 8 (1977) Copyright (~) 1977 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
1SSN 0005-7894
LETTERS TO THE EDITOR
reach agreements about the problem behavior, the pleasing replacement behavior, and a contingent reward. Using the game, families write as many as eleven contracts during training. (d) Objective: Practice contract compliance. Two contracts written by family members are carried out by the family during training weeks until each contract is 70% successful. When necessary, the contract is renegotiated with the game. Other contracts written during training are stored to be carried out after training ends. The last procedure seems to slow down short-term gain in order to facilitate long-term gain family members must learn that patient chipping away at their problems brings a steady reliable flow of small successes. Long-term results of family problem solving training are now being gathered. The balance of power between parents and adolescents differs from that between parents and younger children. The objectives we believe necessary for the success of parentadolescent contingency contracting assume that the nonreciprocal parent training model is inappropriate. The lessened dependency of adolescents upon parents must be taken into account to heighten commitment and compliance. A contractual approach can be used as a method of providing adolescents with a prosocial and desirable method of asserting themselves at home.
REFERENCE NOTES 1. Blechman, E. A., & Turner, A. J. Training and maintenance of family problem-solving: Component objectives and procedures. Unpublished manuscript, Yale University, 1975'. 2. Weiss, R. L., Hops, H., & Patterson, G. R. A framework for conceptualizing marital conflict, a technology for altering it, some data for evaluating it. Paper presented at the Fourth Annual International Conference on Behavior Modification, Banff, Alberta, Canada, 1972.
REFERENCES Alexander, J. F., & Parsons, B. V. Short-term behavioral intervention with delinquent families: Impact on family process and recidivism. Journal of Abnormal Psychology, 1973, 51, 219-233. Blechman, E. A. The family contract game: A tool to teach interpersonal problem solving. Family Coordinator, 1974, July, 269-281. Blechman, E. A., Olson, D. H. L., & Hellman, I. D. Stimulus control over family problemsolving behavior. Behavior Therapy, 1976, 7, 686-692. Weathers, L., & Liberman, R. P. Contingency contracting with families of delinquent adolescents. Behavior Therapy, 1975, 6, 356-366. E L A I N E A . BLECHMAN
Yale University School of Medicine 904 Howard Avenue, Ste. 2C New Haven, CT 06519 RECEIVED: May 2, 1976
Self-Control Treatment of an Eye Blink Tic To the behavior therapist, tics are behaviors with unusual sources of strength, but behaviors which are explained and treated by learning theory derived techniques, such as operant treatment procedures or mass practice procedures (Schaefer & Martin, 1969; Barrett, 1962; Schulman, 1974; Yates, 1958). Most operant treatment procedures used to
BEHAVIOR THERAPY 8 (1977) Copyright@ 1977by the Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin~anyformreserved.
ISSN 0005-7894
278
LETTERS
TO
THE
EDITOR
treat tics are externally Controlled, and mass practice procedures might appear paradoxical and be difficult for the patient to accept as a viable treatment method. Azrin and Nunn (1973) reported successful habit reversal methods in eliminating such habits and tics as head jerking, lisping, nail biting, and thumb sucking. Their procedures emphasize early detection of tic onset and use focally antagonistic muscle responses in eliminating the tic. Such methods are clearly within the sphere of the client's control and appear to be treatments of choice for such disorders, The following treatment, used to treat an eye-blink tic and similar to Azrin and Nunn's (1973) habit reversal method, is another demonstration of the effectiveness of behavioral treatment in which the patient has direct control over a seemingly uncontrollable response. The patient, a 28-year-old truck mechanic with no former psychiatric history, complained of blinking uncontrollably for the preceding 4 months. The tic was interspersed with bursts of rapid blinking and brief periods of normal blinking, i.e., one blink per 5 sec. By the time he was seen he was unable to work, read, or drive his car. A medical examination had ruled out a physiological basis and pharmacological interventions were refractory. He had also rejected surgical intervention due to a high risk of facial paralysis. He was unable to identify precipitants for the tic. A behavioral analysis indicated the uncontrollable blinking to be present during the patient's waking hours, except during sexual intercourse. An average frequency of 94 blinks per minute were observed in the office during a nonintrusive baseline frequency count. A behavioral explanation of the tic was given: He was told that the tic had become a learned response which had obtained its maximum habit strength as the result of some undetermined stimulus, e.g., stress at work, but that voluntary control of his eye blinking could be learned through therapy. The treatment was labeled "extended practice of eye blink control." The procedure consisted of having the patient stare at selected objects in the office without blinking while the therapist counted out 3 sec. Following the count of three the patient was instructed to blink once. This procedure was practiced during the first and last 10 min of each session. During the fourth and subsequent treatment sessions the patient assumed the counting responsibilities while staring at objects in the room. Additionally, during the fourth session he was instructed to count to five before blinking and to subvocalize the counting. Concurrently, because the patient claimed to be tense, muscle relaxation training was initiated in the office, and a relaxation tape was made available for home use. He was instructed to practice relaxation and eye-blink control twice daily for 10 rain. Because the behavior analysis indicated his wife's attention to be often contingent upon the uncontrolled blinking, his wife agreed to make hugs and kisses contingent on the home relaxation and eye-blink control practice. By the sixth session the patient and his wife reported that he had gained complete voluntary control over the blinking and no evidence of the tic was observed during treatment. Eye-blink control practice was maintained until treatment was terminated after the eleventh session. During the seventh session some instruction in assertion training was provided in response to the patient's complaint of feeling inhibited in certain interpersonal situations. Four months after terminating treatment, the patient called to report that he had started to blink uncontrollably on several occasions. He was instructed over the telephone to start the eye-blink control practice on a daily basis until the blink was again under his voluntary control. If the problem persisted he was told to recontact the therapist. Nine months later the patient was contacted by telephone and reported that the uncontrolled eye blinking had ceased following the brief reintroduction of eye blink practice, and that he had been free of the tic during the subsequent 9 months. The introduction of the eye-blink control practice resulted in immediate decrease in the frequency of uncontrolled eye blinks and total control within six treatment sessions. AI-
BEHAVIOR T H E R A P Y 8 (1977) Copyright ~) 1977 by the Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
ISSN 0~5-7894
279
LETTERS TO THE EDITOR
though this is a single case report with its obvious generalization problems, the specific procedure employed appeared to be highly effective and reinforcing to the patient. This procedure, as well as the Azrin and Nunn's habit reversal procedures, appears to fall within a self-control model and permits the behavior therapist to be effective without assuming control for the patient's behavior.
REFERENCES Azrin, N. H., & Nunn, R. G. Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 1973, 2, 619-629. Barrett, B. N. Reductions in the rate of multiple tics by free operant conditioning methods. Journal of Nervous and Mental Disease, 1962, 135, 187-195. Schaefer, H. H., & Martin, P. L. Behavior therapy. New York: McGraw-Hill, 1969. Schulman, M. Control of tics by maternal reinforcement. Journal of Behavior Therapy and Experimental Psychiatry, 1974, 5, 95-96. Yates, A. J. The application of learning theory to the treatment of tics. Journal of Abnormal and Social Psychology, 1958, 56, 175-182. STEVEN BECK A L S. FEDORAVICIUS
Department of Psychiatry College of Medicine University of Cincinnati Cincinnati, OH 45267 RECEIVED: January 6, 1976
Social Skills Game: A General Method for the Modeling and Practice of Adaptive Behaviors A social skills training program for institutionalized assaultive patients should provide them with the opportunity to make critical judgments of appropriate and inappropriate social behaviors and observe how others judge them, as well as to practice these behaviors and receive feedback on their efforts. The program should be individualized and easy for staff to run. In addition, it should be fun for the patients to participate in and have as few "therapeutic" connotations as possible. As in any behaviorally oriented approach, any reinforcement derived from program participation should be contingent upon the patient's success in acquiring the desirable behaviors. Success in the program should not depend on the patient possessing average or superior verbal abilities. Reinforcement should be provided for cooperative behavior. The program should be focused on the acquisition of the target behaviors and not on an individual's discussions of his criminal exploits or current suspicions. Lastly, the program should lend itself to objective evaluation of patient progress. We believe that the Social Skills game described below has all of these desirable features. First, we will describe the game and then we will discuss how the game fulfills the criteria outlined above.
We wish to thank Cary Steinman for helping us with the design of the game. This research was supported by Grant 536-75A from the Ontario Mental Health Foundation.
BEHAVIOR T H E R A P Y 8 (1977) Copyright (~) 1977 by Association for Advancement of Behavior Therapy. All rights of reproduction in any form reserved.
1SSN 0005-7894