Phase IV: Beginning of the End (Sessions 13-18)
8. CONCLUDING EVALUATION OF THE THERAPY’S PROCESS AND OUTCOME
The Outcome of Hiro’s Therapy
Hiro’s treatment was rocky in the very beginning, but soon after I made the decision to alter treatment to more uniquely fit his presentation, success in treatment picked up significantly.
Hiro’s treatment success can be seen in both the quantitative and qualitative data that is
described below. In general, Hiro learned to use HRT to manage all of the tics that we covered in our 18 sessions together. Additionally, Hiro learned to better recognize his tics and developed a more comfortable relationship with his symptoms. By the end, both Hiro and his parents were content with therapy, enjoyed coming, and walked away with the skills to maintain treatment gains and continue treatment without my direct involvement.
Quantitative Results
As shown in Table 1, when treatment first began, Hiro had a Total Tic Impairment Score of 26 on the Yale Global Tic Severity Scale (YGTSS), which put him in the moderate level of tic severity, and an Impairment score of 10, indicating mild negative impact on general life
satisfaction caused by tics. At the end of treatment, Hiro had a Total Tic Impairment Score of 14,
a 12-point drop, which put him in the mild range of impairment and an Impairment score of 0, indicating no negative impact of tics on Hiro’s general life satisfaction.
At his three-month post-treatment session, Hiro’s Total Tic Impairment score had decreased even more to an 11, maintaining his “mild” range of symptoms. At his six-month follow-up, Hiro’s score was a 14, the same as it was when we completed treatment together.
These scores demonstrate that Hiro and his family were able to continue utilizing his skills to manage his tics even after our treatment together was completed. This low score is even more impressive given the fact that Hiro had only recently endured significant changes (e.g., moving to India, starting a new school, etc.) and that changes often lead to an increase in tic
symptomology. I believe this is a testament to how well Hiro learned tic management skills, to his own flexible and resilient personality, and to the informed support from his parents.
Qualitative Results
The following is a list of our original goals:
-- Develop buy-in for treatment and belief from parents and from Hiro in the efficacy of treatment.
-- Discover and functionally deal with environmental conditions that may increase tic symptoms. x
-- Develop relaxation skills to help manage tics. x -- Create awareness of tics when they occur.
-- Create awareness of premonitory urges before tics occur. -- Develop Competing Responses (CR) to negate tics.
-- Decrease number and frequency of tics as recorded on the YGTSS and SUDS. -- Teach skills so that Hiro can continue creating CRs for new tics post treatment.
There are x’s next to the treatment goals that we dropped and check marks next to the goals that were accomplished. As can be seen, the focuses of treatment after my reformulation of Hiro’s case were on developing a relationship with Hiro and his parents, decreasing frequency and intensity of his tics, and teaching Hiro the skills to maintain treatment goals. By the end of treatment Hiro had made tremendous progress in terms of comfort with his tics, using his CR’s, reducing his tics, and developing skills to maintain and continue his success.
It is instructive to look at Hiro’s Tic Hierarchy (Table 6), and at his Subjective Units of Discomfort Scores (SUDS). For the tics that we had worked on, his SUDS were continuously decreasing, with only the occasional spike in specific or new tics. While this is not a direct indicator of fewer symptoms present, it does reflect how Hiro felt about each tic we worked on after we worked on it. Overall, and more specifically, Hiro’s decreasing SUDS shows a level of comfort developed around his tics that were not there before. Additionally, this level of comfort can be gleaned in the three-and six-month follow-up sessions. Even though Hiro developed new tics, he was confident that he could keep developing new CR’s that would eventually work. His
faith in his own abilities to manage his tics was something that was not present when we first began treatment together but grew over time and continued to grow even through follow-up sessions.
Discussion
Through my treatment with Hiro I learned a number of valuable lessons regarding both manualized treatment and myself as a practitioner. Regarding manualized treatment for TS, as applied to Hiro's case, I discovered the following: (a) Having only eight sessions was too brief for effective treatment; (b) there was nothing in the manual for garnering parental buy-in, which for Hiro's case was critical; (c) there were a very limited number of competing responses provided in the manual, which therefore required significantly greater creativity on my part to invent more; (d) there was no recourse in the manual for particularly challenging tics (e.g., Hiro's grunting tic); (e) the manual did not address Hiro's ADHD comorbidity problem; and, (f) for Hiro's case, there were treatment elements—like the Functional Based Assessment—that were unnecessary and proved unwieldy. This is not to say that the manual did not provide a very solid, basic outline for treatment of TS—it certainly did. But if I had not had the support, knowledge, and help of my supervisor, I would not have been able to provide the service that I was able to deliver.
As Fishman notes in his The Case for Pragmatic Psychology, “Past cases provide guidance for understanding and action in present cases because of those features of past cases which are similar to features of the present cases. In short, we ‘learn from experience’” (1999, p.
192). Given the limited experience I had with clients with TS up to that point, my supervisor, with his significant amount of experience, essentially served as my database for dealing with the challenges of my case. Fishman’s (1999; 2005) pragmatic case study model adequately captured the approach I took with my client, both because it represented the pragmatically inspired, individualized-case-formulation approach I took when deviating from the manual and because it provided a systematic means for evaluating the treatment from a "mixed methods" perspective, that is, from both a qualitative and quantitative perspective (Dattilio, Edwards, & Fishman, 2010).
Ultimately, between my supervisor’s wide array of knowledge regarding treating TS and the tools of the pragmatic case study approach, I was able to treat my client successfully and to the best of my ability. In this sense, the pragmatic case study approach served as the solution for the challenges that the typical, manual-based approach could not. Thus, as mentioned above, if not for my supervisor, I would have been at a loss for how to best treat Hiro. For that reason, I support the notion put forth by Fishman (1999) for a database that could provide numerous case studies—such as this one—for whenever a clinician is faced with the challenges of treating someone for whom a manual, or the practitioner’s general knowledge, is not enough.
Two final, but very important, lessons I learned from working with Hiro are the following. First, Hiro’s own impressive imagination and ingenuity taught me the value of utilizing those same traits in therapy. From Hiro, I learned that the manual will not provide the answers we sometimes need and that, as therapists, we need to tap into our own reservoirs of ingenuity and skills to have the confidence to try new things. For me, this included using
video-game-inspired visualizations to help Hiro with tough tics, and developing a parent-training model for HRT so that Hiro’s family could continue treatment without me.
Finally, I think it can be argued that it was the therapeutic bond I developed with Hiro that contributed so much to our success together. I knew that every week, Hiro looked forward to coming to treatment. A part of that was his own budding sense of self-efficacy when it came to managing his tics. But a large part, I believe, was because I provided a space for him to talk enthusiastically and knowingly about his personal interests with an adult who attentively listened and respected these interests. This contributed so much to our collaborative work together, and I believe we could not have had the success we did without it.
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Table 1: Hiro’s Scores on the Yale Global Tic Severity Scale (YGTSS)
Measure Pre Post 3-month
follow up
6-month follow up Total Tic
Impairment Score*
26 14 11 14
Range of severity Moderate Mild Mild Mild
Impairment Score**
10 0 10 10
Range of severity Minimal None Minimal Minimal
*Total YGTSS score ranges of severity groupings for patients are as follows: 0-9 (Minimal), 10-19 (Mild), 20-30 (Moderate), 31-50 (Marked)
** Impairment Score ranges of severity groupings for patients are as follows: 0 (None), 10 (Minimal), 20 (Mild), 30 (Moderate), 40 (Marked), 50 (Severe)
Table 2: Hiro’s Scores on the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS)
Measure Pre Post 3-month
follow up
6-month follow up Overall
CY-BOCS Score*
18 0 0 0
Range of severity Moderate Subclinical Subclinical Subclinical
*Total CY-BOCS score ranges of severity groupings for patients who have both obsessions and compulsions are as follows: 0-7 (subclinical), 8-15 (Mild), 16-23 (Moderate), 24-31 (Severe), 32-40 (Extreme)
Table 3: Hiro’s Diagnosis at Beginning and End of Treatment
Axis DSM-IV Diagnosis at Beginning of Therapy
DSM-IV Diagnosis at End of Therapy
Axis I 307.23
314.01
Tourette Syndrome Attention Deficit Hyperactivity Disorder—Combined Type
307.23 314.01
Tourette Syndrome Attention Deficit Hyperactivity Disorder—
Combined Type
Axis II V71.09 No diagnosis V71.09 No diagnosis
Axis III None None
Axis IV None None
Axis V GAF = 65 GAF = 80
Table 4: Tic Hierarchy with Operational Definitions of Tics and Competing Responses, page 1 Jaw clenching* Clenching the back
jaw muscles together,
Head shaking up Very quickly jerking head back at a 45
Jaw click A sharp, forceful jerk of the jaw to the left
* Tics are listed in order that they were worked on in therapy sessions
Table 4: Tic Hierarchy with Operational Definitions of Tics and Competing Responses, page 2 travels up to the left side of the head, around the
Tenseness in throat. Tightening throat muscles while imaging a permeable wall, in the area where the premonitory urge is, that lets air in, but does not let
Tenseness in throat. Tightening throat muscles while imaging a permeable wall, in the area where the premonitory urge is, that lets air in, but does not let