Combined habit reversal and acceptance and commitment therapies for tics

[00:00:35] Dr. Jennifer Eisenhauer: Thanks so much for having me, I'm really honoured to be chatting with you today.

[00:00:39] Dr. Sara Schaefer: Today we're going to be talking about your paper in Movement Disorders Clinical Practice. That is about, habit reversal therapy combined with acceptance and commitment therapy for the treatment of tics in Tourette's syndrome. So let's start with just some [00:01:00] definitions because there are a lot of different types of therapy and you know in medical school a lot of us learn about cognitive behavioral therapy and other things like that. But habit reversal therapy is a little bit of a different animal. Can you talk about what that is and how it differs from other types of therapy and specifically other types of therapy for tics like comprehensive behavioral intervention for tics? Is there a difference there?

[00:01:25] Dr. Jennifer Eisenhauer: Yeah, absolutely. I'll start by explaining what Cognitive Behavioural Therapy is, for starters. So that's essentially your gold standard psychological intervention. It has evidence across all different psychological conditions. And it's really based on that framework that our thoughts, feelings, and behaviors are all interconnected.

So each is affecting each other at any one time. There's a real focus on modifying and challenging negative thoughts and behaviors to improve how we're feeling and to promote more positive feelings. And you can think of Habit [00:02:00] Reversal Therapy as an adaptation of Cognitive Behavioural Therapy in that it uses that same framework that our thoughts and feelings affect behaviors. In the case of Habit Reversal Therapy, you're trying to challenge or change the behaviors which are habits. So it's targeted at treating habit disorders such as tics, nail biting, skin picking, hair pulling, etc. There's three main components for habit reversal therapy, so that's psychoeducation, awareness training and competing response training.

So with step one, psychoeducation, you're really trying to give the patient as much information as possible on the neurobiological model of tics. In particular, that, how that urge tic relief cycle is always happening outside of their awareness. You then move on to awareness training and this is when you really try to get the patient to become very aware of how often their tics are actually occurring and what's triggering them.

And also helping them to [00:03:00] identify what their premonitory urges look and feel like to them. And those can be different for each of their tics. So what does it feel like before the tic happens? What are those thoughts that you get before the tic happens? Unpacking all of that with the patient. Then moving on to the main component of habit reversal therapy, which is competing response training.

And that's essentially training the patient in performing a competing response, which is a physically incompatible action to their tic, which will prevent the tic from occurring. So you can think of that as the opposite action to what's involved in doing the tic. So for example, if there's a shoulder shrugging tic competing response would be to tense the shoulders in that downwards position and hold that for 30 seconds up to a minute, or at least until that urge to tic has subsided. So those are the main components of habit reversal therapy. You also would focus a lot on relaxation training as well as exploring the different triggers, so environmental triggers, [00:04:00] internal triggers that may be influencing the frequency and severity of their tics as well. So that's essentially habit reversal therapy.

The way it differs from comprehensive behavioral intervention for tics The two are used quite interchangeably, really. So CBIT, or Comprehensive Behavioral Intervention for Tics, is essentially an extension of habit reversal therapy. And that's when there's just a lot more monitoring involved.

There's a lot more kind of social support involved. It's very much targeted at children as well.

[00:04:31] Dr. Sara Schaefer: Absolutely. And you introduced in your paper is something that's at least new to me, which is the acceptance and commitment therapy that you pair with habit reversal therapy. What is acceptance and commitment therapy and in what context has It classically been used and why do you think it pairs well with HRT?

[00:04:54] Dr. Jennifer Eisenhauer: Yeah. So acceptance and commitment therapy, or what we call ACT, as an [00:05:00] acronym that's part of the third wave of cognitive behavioral therapies, and those are the therapies that incorporate mindfulness processes. So it's a much more modern version of cognitive behavioral therapy, and it's also gaining a lot of evidence to support its use in psychological conditions as well.

The difference is that it focuses on accepting our thoughts and feelings rather than changing them or controlling them, which is more what CBT focuses on and the byproduct of doing that is actually that you get symptom improvement and that's because you're giving less power to those thoughts and feelings.

You're struggling less with them and then you start to feel better in that way. So essentially ACT focuses on being present in the moment or what we know as mindfulness. It focuses on creating space between ourselves and our thoughts. So that whole act of noticing our thoughts as they are, not trying to change them just seeing them come and go throughout our awareness.

And similarly, accepting our feelings as they [00:06:00] are without struggling with them or trying to change them and another big part of ACT is also identifying our values and what's important to us and doing our best to act in line with these values as well to improve quality of life.

So that's acceptance and commitment therapy. I think it pairs really nicely with habit reversal therapy because it's targeting those unpleasant urges associated with tics. So it's providing patients with some techniques to use while they're experiencing those urges, which create a lot of discomfort. Habit reversal therapy. I like to think of as a really good circuit breaker, which is why we did it first in our trial. And that's really disrupting that cycle of that urge tic relief that vicious cycle that keeps on occurring and then acceptance and commitment therapy that's giving the patient techniques that help build their tolerance of those urges. And there's actually some new research that indicates that a higher urge tolerance actually is associated with [00:07:00] lower tic severity or less symptoms as well. So there's definitely a place for acceptance based strategies in the treatment of tics.

[00:07:08] Dr. Sara Schaefer: So you started to mention the protocol of your study. What led your team to want to do it at all? What gap were you trying to fill?

[00:07:18] Dr. Jennifer Eisenhauer: Yeah. Dr. Rick Stell, who's a consultant neurologist and movement disorder specialist at the Perron Institute Clinic. He approached me quite a few years ago now just wondering if I'd be willing to train in habit reversal therapy so that he could start referring patients to me. He obviously had a lot of patients that were experiencing quite heavy side effects with the medications and saw this as another treatment option. At the time I was still doing my training, so I just became heavily interested in the topic. And while treating the patients, I started adding in some acceptance and commitment therapy techniques as well.

Dr. Rick Stell, he was very keen on doing a project in that [00:08:00] area. And given that we knew there was already a large support for habit reversal therapy out there, and we were noticing there was some benefit with ACT techniques as well, we thought, why not combine the two therapies into a protocol and start a trial? 

[00:08:15] Dr. Sara Schaefer: That's awesome. Very organically. 

[00:08:17] Dr. Jennifer Eisenhauer: Yeah. We just happened to be in a really good workplace to make that happen as well. We're a neurological clinic, but we're also a research institute.

[00:08:24] Dr. Sara Schaefer: And how did you actually conduct the study and what did you find? And I just want to clarify your population was adults only with tics and Tourette's syndrome, correct?

[00:08:35] Dr. Jennifer Eisenhauer: Yeah, we're adults only that's correct. Yeah, so our patients were age 16 and older and we did allow comorbidities. As part of the study however, the main thing was that the tics had to be the main problem to the patient. Dr. Rick Stell, he was the study neurologist on the trial and he conducted all the screening of patients. Myself and Dr. Alison Buckland, we conducted the patient assessments [00:09:00] and that involved our primary outcome measure, which was the Yale Global Tic Severity Scale, which is a clinician rated assessment, as well as the Modified Rush Video Rating Scale, which is a video assessments or a more objective measure of tics. Those video recordings were then rated by a neurologist, so scored by a neurologist. The intervention was conducted over eight weeks, so eight one hour sessions held with the therapist, and that was myself. And then we repeated those assessments immediately following the treatment and at six and twelve month follow up reviews. 

[00:09:36] Dr. Sara Schaefer: What did you find?

[00:09:38] Dr. Jennifer Eisenhauer: Yeah, so what we found was that tic severity was significantly reduced over the course of treatment, so we found almost a 19 percent reduction in Yale scores and a 22 percent reduction in the video assessment scores. And those reductions were actually maintained at 6 and 12 month follow ups as well.

So it was really exciting to [00:10:00] see that the benefits from the treatment were lasting in this cohort. And so those findings suggested that this combined intervention had potential to be effective as a treatment for tics.

[00:10:11] Dr. Sara Schaefer: Yeah, what I found really exciting about that one strength of the study was that you showed this long term effect up to 12 months, but also that the therapy that you were providing was just A short term therapy, it didn't have to be an ongoing therapy for the whole 12 months.

Correct.

[00:10:30] Dr. Jennifer Eisenhauer: Yeah, correct. Yep. So just eight weeks. Yeah.

[00:10:33] Dr. Sara Schaefer: So from an implementation perspective that allows more patients probably to go through the system than otherwise would be possible with something that required ongoing practice. Right?

[00:10:46] Dr. Jennifer Eisenhauer: Yeah, absolutely. I think that's where the ACT techniques can be really helpful. Yeah, they really provide a lot of long term use in their techniques. 

[00:10:54] Dr. Sara Schaefer: So we talked to about. A couple of the strengths. This was a [00:11:00] pilot trial. I think we should at least mention some of the limitations of the study. And of course, related to that, what are the next steps to determine if this is, in fact, an effective strategy for patients with tics? going forward.

Does your team have any other plans or thoughts on what you want to do next?

[00:11:19] Dr. Jennifer Eisenhauer: Yeah, definitely. So being a pilot trial, obviously the main limitation was the small sample size and also that we didn't have a comparator in the study. So we just had that one treatment arm. Our team always planned to use the findings from this study to conduct a larger study. So a randomized control trial.

So we really want to compare our combined intervention with habit reversal therapy alone, and see whether ACT has any potential in enhancing those effects of habit reversal therapy. We're also really interested in assessing relapse risk as well, and the long term benefits from treatment. and gaining information on other clinical variables [00:12:00] involved in relapse. Funding's obviously a big challenge in research but yeah, we're very eager to find the resources we need to get it underway, because we think it'd be a really valuable opportunity for patients here in Perth as well, without much access to treatment.

[00:12:13] Dr. Sara Schaefer: Sounds great. So, you mentioned access, which is a wonderful segue into my next question, and I'm sure that this varies. extremely significantly based on where you are in the world. One of the first things that I thought of when reading your paper is this is all well and good, but I can't find a single person who will do habit reversal therapy for my adult patients.

So I imagine that there would be significant barriers to implementation in a lot of places. I guess one of the advantages that we already talked about is that it's just a short course, two months and then you're done. Which is great for access. But do you have any thoughts about that particular aspect of this?

[00:12:55] Dr. Jennifer Eisenhauer: Yeah, that's a really good question. I have thought a lot about that actually. So obviously [00:13:00] we're very aware that training in any new treatment approach for therapists is very time consuming. One advantage, however, is that ACT is already very widely used as a treatment approach by therapists. So many therapists would already have the toolkit for providing this type of treatment, at least the foundation for it anyway. So whereas habit reversal therapy, it's definitely more of a challenge to find therapists that are familiar with it, at least here in Australia. So we suspect either with habit reversal therapy on its own or combined with acceptance and commitment therapy, it just presents a similar challenge in implementation.

So yeah, I guess that's the main barrier we've discussed in implementation of the treatment. I would really like to see more therapists get involved in this type of therapy with this cohort. So I'm hoping the fact that we're using ACT in this approach, that it creates a bit more of a buy in for therapists who are already familiar with the treatment.

[00:13:59] Dr. Sara Schaefer: Absolutely. [00:14:00] And I have to imagine that it's very gratifying. For you as a psychologist being able to take these patients who may have tried a lot of medications with lots of side effects that don't even work very well and who may have a lot of social isolation or be able experiencing other stigma from their tics.

In fact, we did an episode on tics and stigma at the end of 2024. I have to imagine that as a psychologist, it's a really lovely population to work with. And you can see really tangible, physical and emotional results for those patients.

[00:14:37] Dr. Jennifer Eisenhauer: Yeah, absolutely. Every patient I worked with, the amount of appreciation they had for the treatment was profound. It was really amazing to see. And like you said, seeing those results physically as well. And how they impacted their social life, their work life school life as well. So yeah, it was really encouraging. 

[00:14:59] Dr. Sara Schaefer: Great. [00:15:00] Well, maybe some of our listeners will get inspired.

[00:15:04] Dr. Jennifer Eisenhauer: Yes. Yes. I hope so. I would love more people to be to just know about this area of work. It's really rewarding.

[00:15:12] Dr. Sara Schaefer: Thank you for your work and for, trying to find the ideal combination for these patients. And thank you for joining us on this podcast.

[00:15:20] Dr. Jennifer Eisenhauer: Oh, thank you so much for having me today. It's been a pleasure.