Behavioural therapies and Tourette Syndrome
Behaviour therapy is a way of doing something to control your tics rather than taking medication, and it is possible to use behavioural therapy alongside other medical treatments.
Behavioural therapy can be useful for most people with tic disorders, although most evidence suggests that it is effective for children older than eight years of age and adults. Behavioural therapy is not a cure but can be very effective in helping people to gain control over their tics in situations where they would like to do so.
The most commonly validated behavioural therapy is called Habit Reversal Therapy (HRT), which has been researched since the 1970s. More recently, HRT has been shown to be effective as part of a package alongside other elements of therapy, known as Comprehensive Behavioural Intervention for Tics (CBiT).
Comprehensive Behavioural Intervention for Tics
CBiT is a combination of the following elements:
Learning about Tic Disorders and Tourette syndrome. The sorts of information that is typically included in psychoeducation is: understanding the causes (as much as they are known), appreciating that it is a brain-related condition, the usual course of tics and the sorts of co-occurring conditions that often occur in individuals with Tourette syndrome. This is only the beginning and there is much more to learn and understand, which can really help cope with having a tic disorder. Feeling comfortable and confident in what you know about having a tic disorder is very important and remembering that having tics is only a very small part of any person.
Functional analysis is used to identify environmental events that be make tics worse or maintain tics for an individual. A therapist will help a person with tics to understand what tends to happen before and after a bout of tics. This may include reactions to situation, thoughts or feelings that a person has in a particular place and the way in which other people respond to that person when they tic. The therapist will then work with the person to reduce or get rid of tic increasing situations. Relaxation or the ability to look at the situation in another way may help.
Habit Reversal Therapy
The first stage of HRT is tic description and awareness. This involves the person identifying all of their tics in detail. Understanding where they occur in the body and which muscles are involved. Then the person is asked to choose the tic which bothers them most from the list of current tics. The therapist will then help the individual become aware of when that tic is about to occur. Increasing the persons’ sense of when a tic is about to happen , called a premonitory urge (i.e. ‘feeling that a tic is about to emerge’), will help them to control it.
The next stage is finding a competing response. This trains the person to perform an intentional movement, which means that the tic cannot happen. It should not look more unusual that the tic and does not interfere with the persons activities. For example, if somebody has a motor tic which involves flinging their arm out, they can be taught to channel the premonitory urge into something more favourable such as placing their hand on their leg and pushing gently. This approach is then applied to the list of tics. People can get really good as creating their own competing responses once they understand the principle of how to do it.
Social Support and Reward System
Having support from another person is very helpful with getting to know how to do the Competing response and for motivation to continue doing it over time. This is usually a parent or carer for children and a close friend or partner for adults. It can be helpful to set up a reward system in which the child receives praise or points which can be exchanged for prizes when they put great effort into getting to know how to control their tics.
Relaxation is used to reduce the stress that a person with tic disorders experiences. This is included in therapy because of the idea that having stress makes a person less well able to control their tics. The most common relaxation training involves deep breathing combined with progressively tensing and relaxing the muscle groups in your body.
CBiT is usually offered in 6-10 weekly or fortnightly sessions but this can depend on the person with tics and the therapist. There is evidence to show that following the CBiTs protocol completely using telemedicine (similar to voice over internet / Skype) can be just as effective, so this is an approach we are hopeful will be more widely available in the future. You can read more information about telemedicine on our web page
An interesting article looking at research into tic suppression and the environmental effects of tics can be found here.
If somebody is already seeing a behavioural therapist or clinical psychologist, they could recommend a therapist’s workbook on HRT to their clinician: Managing Tourette Syndrome: A Behavioral Intervention for Children and Adults Therapist Guide (Treatments That Work)’ by Douglas W. Woods, John Piacentini, Susanna Chang, Thilo Deckersbach, Golda Ginsburg, Alan Peterson, Lawrence D Scahill.
The Tourette Association of America has produced a four part video series featuring Douglas Woods, Ph.D that demonstrates the behavioural treatment option for tics while showing that a non-medication treatment can be just as effective in reducing tic-severity.
Other major therapies for Tourette Syndrome and associated conditions
Exposure and Response Prevention (ERP)
ERP is another type of therapy that focuses on getting used to the premonitory urge. Although the full programme available for work with children (Tics - Therapist Manual & Workbook for Children Cara Verdellen, Jolande van de Griendt, Sanne Kriens, Ilse van Oostrum)is similar to CBiTS in many ways, in that it involves relaxation, functional analysis and social support, the key ingredient is about suppressing tics. During therapy, the therapist will use strategies to make the premonitory urge as strong as possible and encourage the child or adult to get used to the feeling without doing the tic. There is evidence to suggest that this approach is as effective as CBiTS. Exposure and Response Prevention may be best suited to people who have a range of very annoying tics or are younger.
Cognitive Behavioural Therapy (CBT)
CBT is a type of therapy that focuses on helping people to change both their thinking (cognition) and how they act on it (the behaviour). The technique focuses on current problems and aims to give practical results. For example, it helps to challenge any negative behaviour and thoughts, and builds on the notion that changing our behaviour can help to make us feel better. CBT is based on scientific methods and the efficacy has been proven in research trials. CBT is increasingly more accessible in the NHS, and it’s often a choice for treating problems such as depression, anxiety and Obsessive Compulsive Disorder (OCD).
Access to behavioural therapy
Behavioural therapy is practiced by clinical psychologists. NHS referral to a clinical psychologist is mainly from professional sources including hospital consultants, psychiatrists, occupational therapists, nurses, physiotherapists and sometimes GPs. Tourettes Action’s list of behavioural therapists includes clinicians working in both the NHS and privately.
If you wish to access a clinical psychologist privately then it is advised that you request a referral from a qualified health professional or make contact with a clinician using a website which lists only qualified members such as www.achippp.org.uk, who may have a specialist interest in working with people with tics.
This information was produced by Tara Murphy, Consultant Clinical Psychologist, Great Ormond Street Hospital NHS Foundation Trust, London, in July 2013.
Information from Tourettes Action
Tourettes Action holds a list of HRT therapists in the country which can be given out on request. Please email our Helpdesk for a copy.
If you are a therapist and would like to be added to the list please contact us with your details.