Investigating young people’s experiences of successful or helpful psychological interventions for tic disorders: An Interpretative Phenomenological Analysis study

Abstract

There is emerging evidence for talking therapies in the treatment of tic disorders. This study explored experiences of young people who self-identified as having had a successful or helpful talking therapy, in order to understand the phenomenology, value and meaning of outcomes. The experiences of seven participants aged 10–17 years were described in semi-structured interviews and analysed using Interpretative Phenomenological Analysis. Themes included the challenging battle with tics and process of re-defining self-identity, making sense of and managing experiences, the value of control, and spectrum of positive change. The results highlighted valued outcomes that could be incorporated into clinical practice and future evaluation.

Keywords

Interpretative Phenomenological Analysis psychological therapy qualitative methods tic disorder Tourette syndrome

Introduction

Tourette syndrome (TS) is a neurodevelopmental disorder characterised by motor and phonic tics which falls within a spectrum of tic disorders (TDs) (American Psychiatric Association, 2013). TDs are recognised to have a prevalence occurring in at least 1 per cent of the population worldwide (Robertson, 2008). Tics are transient in nature, with typical course following onset between 4 and 6 years of age, peak severity between 10 and 12 years and a decline during adolescence (Bloch and Leckman, 2009).

A limited number of qualitative studies have provided young people the opportunity to describe the impact of TS, revealing how the condition can be distressing, disabling, feel ever-present and create a struggle to fit into society’s expectations (Cutler et al., 2009; Wadman et al., 2013). Across childhood years, individuals develop their self-identity, integrate within social networks and engage in education, yet Eddy et al. (2011) highlight that TS can have a negative impact on young people’s quality of life, at this crucial stage of development. Conelea et al. (2013) identified a potentially enduring impact, reporting that adults with TS experience a greater frequency of psychological difficulties, disability and impaired quality of life in comparison to population norms.

Difficulties occurring alongside TDs are common, with concurrent psychopathology reported in up to 88 per cent of clinic patients (Freeman et al., 2000; Robertson, 2006, 2008). People with TS commonly present with Obsessive Compulsive Disorder (OCD), Attention Deficit Hyperactivity Disorder (ADHD), Bipolar Affective Disorder, anger outbursts, sleep disturbance, anxiety, low mood, specific learning disabilities and social communication difficulties (Freeman et al., 2000; Robertson, 2006). Some authors postulate that such difficulties may present a core part of the condition, given the high frequency of co-occurrence (Robertson, 2008). Leckman et al. (2014) highlight these commonly co-occurring difficulties to potentially be more enduring and debilitating than tics. In light of this, they advocate enhancing self-esteem through independence, friendships and interests, to foster positive adulthood outcomes. Bloch (2008) also iterates how interventions should aim to improve social functioning and enhance quality of life rather than eliminate tics, due to the limitations of pharmacological interventions.

European guidelines for the treatment of TDs include pharmacological, behavioural, psychosocial and neurosurgical techniques (Müller-Vahl et al., 2011; Roessner et al., 2011; Verdellen et al., 2011). Many treatments for TS focus on tic suppression. Pharmacological interventions have been found to reduce tics, but with variable efficacy and potential side-effects (Bloch, 2008; Waldon et al., 2013). Efficacious psychological interventions for TDs include behaviour therapies such as Habit Reversal Therapy (HRT; Himle et al., 2006), Cognitive Behavioural Therapy (CBT; O’Connor et al., 2009), the Comprehensive Behavioural Intervention for Tics (CBIT; Woods et al., 2008) and Exposure and Response Prevention (ERP; Verdellen et al., 2004). Randomised Controlled Trials (RCTs) of behaviour therapy for TS have identified significant decreases in tic severity with potentially long-lasting effects for both children and adults, as rated by tic severity, impairment and clinical impressions of improvement (Piacentini et al., 2010; Wilhelm et al., 2012). Meta-analyses of behaviour therapy revealed medium to large effects, comparable to medication RCTs (McGuire et al., 2014), and reviews have revealed HRT to be the best-studied, most widely used therapy for TS, with sufficient evidence for efficacy (Frank and Cavanna, 2013).

Intervention success has mostly been evaluated by tic frequency reduction, or improvement on psychometric measures of psychological distress. However, there is little evidence to describe the meaning, value and experience of helpful, successful therapies from the individual’s perspective.

The phenomenology of TS and TDs is varied and complex in nature, and a wide variety of multidisciplinary services can offer support for tics and related difficulties; however, services appear to be of limited availability. Capriotti et al. (2014) reported relatively few professionals to be trained in behaviour therapy and described professionals’ hesitancy about therapy processes, for example, perceiving that treating certain tics may cause new tics to emerge, despite no evidence to suggest this. This limited provision and knowledge about what constitutes successful or helpful treatment potentially creates perceptions that only specialist centres are able to meet individuals’ needs, and as a result, people may struggle to access support.

Aim

The purpose of this qualitative study was to capture young people’s experiences of having received a psychological intervention in relation to their tics, which they perceived to be successful or helpful. The study was exploratory in nature, therefore having no definite hypotheses, but endeavoured to contribute to the evidence base about helpful psychological interventions for tics.

Method

Interpretative Phenomenological Analysis

With origins in phenomenology and hermeneutics, Interpretative Phenomenological Analysis (IPA) draws upon psychological, interpretative and idiographic concepts (Smith et al., 2009). The IPA methodology facilitated an open, exploratory approach through the analysis of language, to capture and interpret emergent themes from the convergence, divergence and nuance of descriptions shared by participants at interview (Smith et al., 2009).

Recruitment

The study obtained National Health Service (NHS) Research and Ethics Committee and University approval (reference: 13/NW/0207). Purposive sampling utilised three recruitment avenues: the UK charity Tourettes Action and two specialist TD clinics in London hospitals. Recruitment was disseminated through web sites and support groups with Tourettes Action and postal-distribution or staff in clinics. Parents and young people all provided informed consent and assent, respectively.

Inclusion criteria specified that participants

had experienced tics (specific diagnosis not required);

had received a psychological intervention for tics;

perceived the therapy as successful or helpful for addressing tics in some manner;

were aged 9–17 years at the time of therapy;

participated within 2 years of completion of the component of therapy which they perceived as being helpful/successful.

Participants were recruited regardless of therapeutic modality as the study sought to explore helpful treatment components beyond specific therapeutic techniques. Medication use and co-occurring difficulties were therefore also not a rationale for exclusion; however, such factors were recorded for consideration in analysis. This facilitated a sample comparable to populations with tic-related difficulties typically presenting to services. Exclusion criteria refused non-English speaking participants due to IPA being immersed in linguistic analysis and no available provision for interpreters.

Questionnaires

Measures collating demographics, tic-related descriptions and therapy outcomes were administered prior to interview in order to describe the sample. Two standardised psychometric measures captured the nature and perceived impact of participants’ tics. The first was researcher-rated (in collaboration with the participant): the Yale Global Tic Severity Scale (YGTSS; Leckman et al., 1989). The second was self-rated: the Motor tic, Obsessions and compulsions, Vocal tic Evaluation Survey (MOVES; Gaffney et al., 1994). An un-standardised questionnaire retrospectively rated quality of life, confidence, control, anxiety and low mood on visual analogue scales (1–10) to contextualise individuals’ experience of change after therapy.

Interviews

Interviews followed a semi-structured, exploratory, reflexive format and avoided leading questions, in line with the IPA methodology (Smith et al., 2009). The interview explored participants’ stories of experiencing therapy and whether they perceived it as helpful, successful or something else. The researcher enquired about what sessions provided, what helped, what changed and what this meant to them. Direct interviews enabled warm rapport, lasted 40–80 minutes and were conducted at clinic sites, local facilities or individuals’ homes. It was preferable to see participants alone, however if more comfortable with parents, this was deemed appropriate and parents were asked to remain silent. Homogeneity was sought through inclusion criteria, sampling and semi-structured interviews to guide focus.

Analysis

Interviews were audio-recorded and transcribed verbatim, with identifiable information removed to ensure anonymity. Data were analysed according to the IPA methodology (Smith et al., 2009), following an iterative and inductive cycle (Smith, 2007). Transcripts were read multiple times, and line by line analysis identified emergent patterns/themes within and across participants, through noting content, language and conceptual ideas. Emergent themes developed, the dataset grew and the researcher sought to reduce the volume of detail, yet maintain complexity by mapping interrelationships. Careful consideration noted nuance, as well as convergent or divergent ideas through detailed analysis, and scrutiny with the research team to ensure rigour yet sensitivity. This was an exploratory process in which reflexivity and transparency were key throughout, and a reflective journal was utilised to capture decision-making processes, learning and reflections.

The lead researcher was a female trainee clinical psychologist in her late 20s. She had no prior personal or clinical experience of TS/TDs. However, she was interested in eliciting a clinical contribution for a population with seemingly limited resources. The research team comprised clinical psychologists, a neuropsychologist and neurologist, who had clinical experience of working with TDs and/or qualitative research.

Results

The sample encompassed seven young people aged 10–17 years, including two females and five males. All participants were of White-British ethnicity and in full-time education at the time of interviews (Table 1). Demographic data contributed to sample homogeneity. Characteristics were carefully considered at each methodological stage and throughout analysis to ensure nuance and also homogeneity were retained wherever possible; for example therapy-specific, medication-relevant or developmental differences. The varied number of sessions of treatment and therapeutic modalities highlighted a range of interventions to be perceived helpful. The term ‘TS’ is used throughout to encompass participants’ diagnoses/experiences of tics.

Table 1.

Participant data.

	Participant
	1	2	3	4	5	6	7
Gender	Male	Female	Male	Male	Male	Female	Male
Age (years)	17	17	11	10	10	16	12
Presenting difficulties
Diagnosis	Tourette syndrome	No diagnosis; tics	Tourette syndrome	Tourette syndrome	Tourette syndrome	Tourette syndrome	Transient tic disorder
Other difficulties reported	None	Anxiety	OCD	Anxiety traits	None	ADHD traits	None
Interventions
Participant description of therapy	CBT and mindfulness	CBT	Group workshop	HRT and ERP	CBT	Person-centred counselling	Systemic family therapy
Number of sessions	11–15	5–10	5–10	11–15	5–10	>16	2–4
Medication	Yes (Risperidone)	No (yes previously)	No	No	No	Yes (Risperidone and Sertraline)	No
Measures
Therapy outcomes (visual analogue scale 1–10)
Quality of life			Average = 4.14 increase (range = 2–6 prior to therapy; 7–9 post)
Anxiety			Average = 3.15 decrease (range = 4–10 prior to therapy; 2–8 post)
Confidence			Average = 4.28 increase (range = 1–6 prior to therapy; 6–10 post)
Low mood			Average = 4.13 decrease (range = 4–10 prior to therapy; 2–4 post)
Perceived control			Average = 5.14 increase (range = 1–5 prior to therapy; 5–9 post)
MOVES
Tic scale			Average = 8.86 (range = 4–19)
Obsession/compulsion scale			Average = 5.43 (range = 0–16)
YGTSS
Tic severity score			Average = 22.14 (range = 8–48)
Total YGTSS score			Average = 39.29 (range = 13–98)

OCD: Obsessive Compulsive Disorder; ADHD: Attention Deficit Hyperactivity Disorder; CBT: Cognitive Behavioural Therapy; HRT: Habit Reversal Therapy; ERP: Exposure and Response Prevention; MOVES: Motor tic, Obsessions and compulsions, Vocal tic Evaluation Survey; YGTSS: Yale Global Tic Severity Scale.

Measures

Measures provided descriptive context. Retrospective ratings evaluated pre- and post-therapy outcomes across five domains, including quality of life, anxiety, confidence, low mood and perceived control. All domains exhibited marked improvement. MOVES and YGTSS scores identified considerable variation across participants’ tics, suggesting that despite a potentially enduring, impairing presence, positive outcomes can be acquired. Tic frequency and severity reduced for many participants after therapy; however, all continued to experience tics, and one participant reported her tics to be worsening (thus deviating from typical course for her age; Bloch and Leckman, 2009).

At interview, some participants exhibited no tics, and some high frequencies. One participant required frequent repetition of questions following lengthy bouts of tics, however, positive rapport and engagement ensured rich data and insight.

IPA themes

Analysis revealed five super-ordinate themes to capture participants’ experiences of positive, helpful therapies:

The challenging battle with TS and the sense of self.

Making sense of the lived experience.

Useful strategies to manage experience.

The meaning and regaining of control.

The spectrum of positive change.

Therapy appeared to involve a challenging battle with TS, which facilitated a re-defined self-identity, increased sense of control, acceptance, adjustment, understanding, helpful strategies and spectrum of positive outcome. Participants’ language revealed frequent terminology relating to teaching and learning, which highlighted that the therapist potentially held two roles in a helpful process, of confidant and tutor. This was tentatively considered, because participants were in full-time education and may equate professional roles most commonly with teachers.

Theme 1 – the challenging battle with TS and the sense of self

Participants reflected that prior to therapy, TS was regarded as unwanted, negative and holding a destructive presence, with experiences of self-injurious tics, or otherwise disrupted functioning reported. Within these reflections, participants’ language rarely encompassed ownership of TS, rather individuals perceived TS as almost external to the self, utilising terms including ‘it’, ‘they’ and ‘the tics’. The enduring, ‘irritating’ presence of TS was apparent; participants’ language suggested disliked and aggressive experiences through vivid metaphor, description and analogy:

… annoying like a wasp is annoying, it never goes away … (Participant 3)

These reflections encompassed how negative social perceptions appeared internalised, with individuals recognising their identity to be defined or lost somewhat by seeking social integration and hiding tics. Young people described a loss of purpose, self-worth and self-respect:

I’d already changed, but then I kind of wanted to change back … Back to myself, ‘cause I wasn’t myself … but I felt I had to be like that otherwise, I dunno, people might judge me in a certain way … (Participant 7)

In contrast, a battle with TS emerged through the process of helpful therapy: ‘like pest control!’ (Participant 5). Individuals moved from feeling isolated to engaging in a position of control; re-defining a positive self-identity and building resilience, to ‘… not let them get the better of you’ (Participant 3). Participants’ vivid language suggested striving for adaptation to the negative, consuming repercussions of TS, and how therapy facilitated a refreshing contrast to feelings of emptiness, or a lost sense of self which was consumed by TS.

… so empty I wasn’t a person anymore, I was basically just a machine that hit things and shouted, and I went from that, and then went to do all the therapy, discovered myself and it’s like just basically, just got filled – my head got filled with things one by one. I was getting re … re-fuelled basically with esteem, and life … (Participant 1)

Acceptance and adjustment to TS developed throughout therapy. Positive change was often linked with control, acceptance, or perceiving the self as normal and valued. A sense of control over tics facilitated individuals feeling like ‘… a better person’ (Participant 3). There appeared a balance between motivation to change what was possible, and an acceptance of residual difficulties or tics. The enduring journey promoted self-respect, resilience and strength over time, enabling individuals to integrate socially and realise their potential. Negative social experiences were externalised and less destructive, therapy taught individuals that they need not seek different, ‘perfect’ identities. Many identified that after therapy, TS felt integrated into the self and personality; a positive synthesis representing a pertinent transition about what TS meant to them:

I would go through all the Tourettes and everything bad … just to get to this point in my life, to be a much stronger person. (Participant 1)

Theme 2 – making sense of the lived experience

Individuals valued the opportunity to make sense of phenomenology linked to their TS – a therapeutic experience, which facilitated opportunity for change or control. Therapy was described as a collaborative process between the therapist, young person and often family. Linguistically, many participants fluctuated between ‘I’ and ‘we’, suggesting perceived high levels of support from others:

[therapist] kind of painted a better picture in my mind of everything that was going on … (Participant 7)

Interpersonal qualities

The interpersonal qualities and values of the therapist were appreciated. Therapists were experienced as reassuring, accepting, non-judgemental, relaxed, empathic, good at listening, someone they could ‘trust’ and who normalised TS. This appeared to model an accepting, non-judgemental social relationship. Sessions were perceived as ‘… a sanctuary’ (Participant 6): a safe place to tic, talk and reflect, without annoying others or feeling stigmatised by their condition. It appeared that such qualities of the therapeutic space offered participants the opportunity to explore who they were and to define their sense of self beyond tics. These positive experiences appeared to then be internalised:

… I’ve been labelled a lot in my life, that’s why it’s so refreshing to have someone like [therapist] just talking to you as a person not just like a patient. (Participant 1)

Indirect treatment for tics

Participants insightfully reflected upon the bi-directional nature and strong interplay between tics and emotional experience, which all therapeutic modalities addressed. HRT, for example, created control over tics, following which individuals experienced changes in mood, whereas counselling addressed mood and indirectly facilitated a positive, calming effect on tics. Some young people valued addressing mood above tics directly:

they got my mood up which meant I was more confident myself and that meant that I had … I felt I had more control, which meant that I was less anxious, which meant that actually I had more control of my tics, which meant actually I got better … (Participant 2)

Both group and individual interventions were valued. Groups were experienced as normalising of TS, and individual interventions offered a personally tailored space to talk and consider strategies for example.

Strategies to control or adapt to tics were highly valued; however, this alone was perceived to be not enough – individuals experienced helpful therapies as multi-faceted, addressing many difficulties. Participants’ terminology varied between ‘successful’ and ‘helpful’, suggesting that successful therapy ideally removes tics. Despite this, acceptance and increased control facilitated positive adaptation in a fluctuating experience of tics.

The on-going process

Many participants identified that therapy was the start of an on-going, adaptive process beyond the completion of sessions, perhaps due to the transient nature of TS and desirability to control tics and avoid negative social perceptions:

I think it’s just a rolling ball that I’ve gotta keep developing myself. (Participant 2)

Theme 3 – useful strategies to manage experience

All participants identified therapy with providing strategies to manage their experiences, through adaptation, control and resilience. The therapist’s role as tutor became apparent through participants utilising language including ‘lessons’, ‘learnt’ and ‘taught’, suggesting a guiding role, with expertise.

Strategies: controlling tics

Strategies to control tics were valued, and techniques appeared broadly consistent with HRT, ERP, Mindfulness and CBT-related approaches. Many reported that early stages of therapy had been difficult striving to acquire control over TS and feeling apprehensive about what therapy would involve. Practising strategies was found to be stressful initially and amplified symptoms due to a perceived lack of control:

… ‘cause I’m holding them in, it puts pressure on me … that makes me stressed and then makes me upset … but I know it’s helping me at the same time, so … I kind of get on with it – and it kind of makes me happy ‘cause I know it’s helping … (Participant 5)

Negative perceptions about the challenging start to therapy diminished over time, and individuals experienced achievement with practice, which motivated them to develop their ability to control tics. Such experiences suggested tension between potential tutor/confidant roles, yet complementary support through difficult processes. Some individuals described strategies becoming automated, or found that with less attention, tic frequency diminished.

Strategies: managing mood and internal state

Many cognitive and behavioural strategies were considered valuable to manage mood difficulties. Strategies included cognitive appraisals – noticing and challenging negative thinking patterns, behavioural activation – encouraging social engagement rather than withdrawal and strategies to manage anxiety. Breathing techniques and imagery were valued relaxation strategies for changing internal state, producing a calming effect on individuals’ tics:

it sort of … makes me feel relaxed, which makes me feel more in control which makes me able to stop the tics really … (Participant 4)

Strategies: responding socially

Some participants valued addressing experiences of bullying, reasons for others’ behaviour and potential adaptive responses. This appeared to enable resilience to externalise others’ negative reactions, rather than internalise negative self-worth.

Theme 4 – the meaning and regaining of control

Control was a strong, emotive theme arising from reflections. Participants’ language and descriptions reflected how TS can strip someone of control like a developmental regression, and the meaning of control over oneself dramatically changes. Therapy guided individuals to regain a sense of control both physically and emotionally over tics and their associated experiences:

… it’s basically gone from when you was young you have control over yourself, fine – get to 13 – lose it all in a heartbeat, like, lose everything like – I can’t even begin to describe what feeling it is … you gain a bit of control and it’s just so refreshing, it gives you a burst of life … (Participant 1)

Older participants reflected on experiences of medication for tics, with some perceiving it as a useful adjunctive to therapy, and others experiencing negative side-effects, feeling helpless, with further reduced perceptions of control.

Theme 5 – the spectrum of positive change

Individuals experienced multiple positive outcomes beyond expectations ‘… everything changed’ (Participant 5). For many, there was marked reduction in tics due to strategies to directly or indirectly control them. Young people described valuing control of tics in social spaces to avoid stigmatisation, and therefore experienced a less intrusive, disruptive presence of tics, and felt more confident to engage in social activities, education or interests. Individuals reported happiness, pride and achievement over the effortful, challenging process of controlling tics:

it was like humongous change because like they’d been so fierce and horrible and I never expected them to get … this much better (Participant 5)

Beyond stopping tics

Tics remained present to some degree for all participants after therapy. Acceptance, confidence, perceived control and a re-defined self-identity appeared valued outcomes to address on-going experiences. Perceptions of wanting tics to stop changed to accepting a residual presence, in the knowledge that individuals held some control over their experience:

the tics don’t have to go – as long as they’re, um, they’re not as visible as they were – I’m fine with them being there as long as I’m not making all the movements that I was. (Participant 2)

All participants perceived therapy to be life-changing as a result of the spectrum of positive outcomes, and two considered it life-saving (Participants 1 and 6). Participants reported feeling more independent, sociable and outgoing after therapy, no longer holding back as if ‘a weight had been … do you know what I mean … lifted …’ (Participant 7). Individuals’ confidence and self-esteem increased, they felt enabled to fulfil their potential, held positive perceptions of the future, enjoyed life and foresaw opportunities:

there’s nothing that should stop me, it’s like me who’s stopping me … if that makes sense … (Participant 6)

Discussion

The study elucidated five themes which provided insight to the meaning of young people’s experiences of helpful/successful psychological interventions for tics. In concurrence with Cutler et al. (2009), TS was experienced as a distressing, disabling condition. Multi-faceted therapies entailed a process of making sense of complex phenomenology and battling with the negative, destructive presence of tics to provide positive outcomes. The findings offer information for clinical practice, research and service development.

Buckser (2008) describes a problem of ‘self-presentation’ in TS, where observable tics may define social perceptions, thus making social stigma potentially unavoidable. The experience of the self within the condition was elicited through therapy, as individuals re-defined a more positive sense of self. Their identity appeared no longer defined or consumed by TS, they adopted control, resilience and self-respect, and some integrated TS into their self-identity.

Resisting stigma has been recognised to preserve a sense of self within chronic conditions such as TS (Millen and Walker, 2001). Interventions are often evaluated by tic frequency and psychometric measures of distress, however the valued outcomes identified here may be missed through such methods. Several therapies are considered efficacious for TS (Frank and Cavanna, 2013), and may indirectly ameliorate self-perception via increased control of tics with behavioural strategies. This study also elicited value for young people in understanding phenomenology and experiencing positive interpersonal factors in the therapeutic relationship, which could also be attributable to outcome (Hubble et al., 1999).

Few treatments currently are able to eradicate tics, or in doing so may generate adverse side-effects (Bloch, 2008). Rothbaum et al. (1982) suggested that individuals who adopt understanding and acceptance of aversive events where instrumental control is unavailable experience fewer negative emotional consequences. Young people here adopted acceptance and adjustment within a residual, yet ameliorated presence of tics. Acceptance and control have been linked to adaptation and coping in illness (Schüssler, 1992), and an external locus of control in particular to be associated with psychological difficulties in children with TS (Cohen et al., 2008). Therapy facilitated regaining a sense of control with strategies to directly and indirectly manage tics, mood and internal state. Therapists appreciated the psychosocial impact and transient nature of TS and facilitated generalisable skills for on-going adaptation.

Clinical implications

Components of acceptance, self-identity and self-esteem appear to be unintended, yet valued outcomes. Therapies could more explicitly incorporate such components, perhaps drawing on acceptance-based therapies, or mindfulness strategies, to strengthen clinical outcome and adjustment. Many such interventions are routinely delivered across mainstream mental health services, and in the absence of tic-specific expertise, therapists could draw on these modalities to offer valuable support. Reports from some participants suggest that reducing psychological distress can have an indirect impact on tics, through individuals feeling more relaxed and in control.

Research implications

This study explored positive perceptions of therapy. Future research could investigate therapy outcomes from a neutral perspective, and explore whether therapies are more successfully perceived when components addressing self-identity, acceptance and interpersonal factors are incorporated, together with control over tics.

Many emerging and established interventions for tics exist (Frank and Cavanna, 2013), and further evaluation of treatments has been advocated. Future research could usefully incorporate qualitative evaluation or psychometric measures appreciating valued components such as quality of life, self-esteem or acceptance. In future, the promising TS-specific quality-of-life scale currently validated for young people in Italian by Cavanna et al. (2013) could be used, or visual analogue scales indicating goal-based outcome. The study highlighted how the YGTSS alone has limited scope to capture the wide-ranging, positively perceived therapy outcomes.

Strengths and limitations

Pringle et al. (2011) highlight that IPA research can influence and contribute to theory, in line with Smith et al.’s (2009) consideration of theoretical transferability as opposed to empirical generalisability. The methodological approach yielded rich data, and saturation was apparent with analogous themes emerging across participants (Smith et al., 2009). The lead researcher perceived their position without prior clinical/personal experience of TS as valuable while engaging in the ‘double hermeneutic’ to make sense of participants trying to make sense of their experience (Smith et al., 2009), due to holding few pre-conceived ideas. Journal reflections and team discussion were helpful to ensure interpretations remained embedded and evidenced in data. It could be argued that including different therapy modes may be a limitation of the study. However, the research team perceived this to be a strength by capturing young people’s perceptions of helpful therapeutic strategies. The study potentially provided an empowering voice for participants.

Smith et al. (2009) outline the importance of IPA utilising a homogeneous sample. The sample encompassed participants experiencing tics and positively perceived therapies for tics. However, the age range of 10–17 years was a potential limitation.

Conclusion

Exploring experiences of positively perceived talking therapies captured the phenomenological complexity of TS and provided insight to the most helpful aspects of psychological interventions. These accounts highlight how other, more widely available therapeutic approaches could be helpful in the absence of tic-specific expertise. Beyond increased control, young people valued outcomes relating to confidence, self-esteem, self-identity and acceptance, components which could advantageously be explicitly incorporated into therapies.

Footnotes

Acknowledgements

We thank the UK charity Tourettes Action for supporting recruitment.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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