Pragmatic Case Studies in Psychotherapy

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April 22, 2017 -- From the Editor 


The Case of "Hiro": Treating Tourette Syndrome by Comprehensive Behavioral Intervention for Tics (CBIT)  

*** Jeremy Lichtman, Tourette Syndrome Clinic, Rutgers University-New Brunswick, Piscataway, NJ 


***  Matthew Capriotti, San Jose State University, San Jose, CA  

*** Brianna Wellen & Michael Himle, University of Utah, Salt Lake city, UT  

*** Daniela Colognori & Lori Rockmore, Tourette Syndrome Clinic, Rutgers University-New Brunswick, Piscataway, NJ

Response to Commentaries 

*** Jeremy Lichtman, Tourette Syndrome Clinic, Rutgers University-New Brunswick, Piscataway, NJ    

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Hiro, a 10-year old south Asian boy, presented with Tourette Syndrome, specifically with multiple motor and vocal tics, including simple motor tics such as head jerking and eye blinking; and simple vocal tics, such as sniffing and grunting. In addition, Hiro manifested obsessive thoughts, compulsive behaviors, and symptoms of Attention Deficit Hyperactivity Disorder (ADHD).

A logical treatment choice for Hiro was Comprehensive Behavioral Interaction for Tics (CBIT), an empirically supported, protocol-based treatment manual derived from cognitive-behavioral therapy principles. In implementing this treatment, the therapist--Dr. Jeremy Lichtman--found that in a number of ways, Hiro responded very well to the manual.

However, in other ways, Lichtman found Hiro to be unresponsive, and—with guidance from his supervisor—he thus decided to add to or deviate from the manual to better tailor the treatment to Hiro’s individualized needs.  For example, (a) Lichtman determined he needed 19 sessions for the treatment instead of the 8 called for by the manual; (b) he added a crucial component of developing parental buy-in, which was not in the manual; (c) he had to call upon his creativity to add to the limited number of competing responses provided in the manual to meet Hiro's needs; (d) he needed to add to the manual to deal with a number of Hiro's particularly challenging tics, like grunting; and (e) he had to go beyond the manual to address Hiro's ADHD. In addition, Lichtman de-emphasized certain elements called for in the manual--like Function-Based Assessment--because he found that they were "unnecessary and proved wieldy."

Overall, Hiro's treatment was quite successful both quantitatively and qualitatively. Therefore, a general question emerging from the case and considered by the three sets of commentators is whether the flexibility and creativity Lichtman used in deviating from the CBIT manual--and the rationales for these deviations--were justified. First, Matthew Capriotti finds them justified by preferring a "Principles First" versus a "Protocol First" approach to treatment. In a parallel way, Brianna Wellen and Michael Himle also find them justified by preferring the model of a "Culinarian," who is trained "in the art and science of preparing, cooking, and presenting food" to that of a "Cook," who is trained to strictly follow recipes. Finally, Daniela Colognori and Lori Rockmore take a different position by noting that when Lichtman conducted Hiro's case, Lichtman was a relatively beginning therapist, and perhaps he made some novice errors and should have followed CBIT manual more closely.

In responding to the commentaries, Lichtman advocates for the importance of balancing the arguments for a "mechanical/algorithmic" versus a "flexible/creative" approach in applying a therapy manual. To accomplish this balancing he emphasizes that an understanding of the principles underlying the manual is the best way to bridge the two approaches.  

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Vol 13, No 1 (2017)

Table of Contents

Case Study

The Case of "Hiro": Treating Tourette Syndrome by Comprehensive Behavioral Intervention for Tics (CBIT) Abstract PDF
Jeremy D. Lichtman 1-37
On Protocols and Principles in the Case of Hiro Abstract PDF
Matthew R. Capriotti 38-50
From Cook to Culinarian: Going Beyond the Manual When Delivering Behavior Therapy to Treat Tourette Disorder Abstract PDF
Brianna Wellen, Michael B. Himle 51-62
Perspectives on Training Clinicians to Effectively Implement Evidence-based Treatment for Tourette Syndrome Abstract PDF
Daniela Colognori, Lori Rockmore 63-72
Mechanical/Algorithmic Versus Flexible/Creative Clinical Practice: How Underlying Principles Bridge the Gap Abstract PDF
Jeremy D. Lichtman 73-81