The goal of competing response practice is to teach the client to engage in a competing response each time the habit behavior occurs or when an antecedent to the habit behavior occurs. The therapist implements competing response practice after awareness training is completed, and the client can identify each occurrence of the habit or antecedents to the habit.
To begin competing response practice, the client (with the aid of the therapist) chooses one or more competing responses that can be used in situations in which the habit behavior typically occurs. The therapist instructs the client that the competing response should be a behavior that is, (a) physically incompatible with the habit behavior, (b) easy for the client to engage in, and (c) inconspicuous so that the competing response does not draw attention to the client when the client is around others. An example of a competing response for hair pulling or thumbsucking might be to make a fist while holding the hands down at the side. An example of a competing response for a motor tic such as head jerking might be to tense the neck muscles while pulling the chin down slightly toward the chest. The therapist instructs the client to engage in the competing response for about one minute each time the habit behavior occurs or when an antecedent to the habit behavior occurs. After choosing the competing response(s), the therapist has the client practice use of the competing response contingent on the habit or antecedents to the habit in the session.
If the habit behavior occurs naturally in session (e.g., tics or stuttering), the client practices use of the competing response each time the habit occurs. The therapist praises the client for using the competing response at the appropriate time and prompts the client to use the competing response if the habit occurs but the client fails to use the competing response. This practice continues until the client reliably uses the competing response immediately contingent on the habit. The therapist also has the client practice use of the competing response contingent on the antecedents to the habit. After reviewing the antecedents with the client, the therapist instructs the client to use the competing response each time one of the antecedents occurs. If the antecedents are overt, the therapist will provide praise for correct use of the competing response or prompts to use the competing response if the client did not use it at the correct time. If the antecedents are covert, the therapist cannot provide such feedback but rather praises the client for reports of successful use of the competing response contingent on the covert antecedents.
If the client's habit behavior does not naturally occur in session (e.g., nail biting, hair pulling), the therapist will implement competing response practice as described above as the client simulates the habit behavior and the antecedents to the habit behavior. For example, the client will reach up to her scalp to simulate a hair pulling behavior, stop the behavior, and immediately engage in the competing response. During competing response practice, the client will simulate a variety of ways that the behavior may occur or a variety of situations in which the behavior occurs and implement the competing response. The therapist will have the client practice the competing response in about 10 to 12 simulations of the behavior or antecedents to the behavior. After the competing response practice is completed in the session, the therapist instructs the client to use the competing response outside of the therapy session every time the habit behavior or an antecedent to the habit behavior occurs.
After implementing the awareness training and competing response practice procedures with the client in the initial treatment session, the therapist then conducts a number of followup or booster sessions to evaluate the client's progress using the procedures to control the habit behavior outside of the treatment session. In followup sessions, the therapist will review the procedures and have the client practice the procedures. The therapist will review difficult situations and help the client identify ways to consistently use the competing response in those situations.
The success of the competing response training procedure depends on consistent use of the competing response contingent on the occurrence of the habit or the antecedents to the habit. The competing response produces reductions in the habit behavior through one or two behavioral processes. Use of the competing response may function as an activity punisher. Thus, the contingent use of the competing response would punish the habit behavior. The other possible explanation for the effectiveness of the competing response in reducing habit behaviors is that the competing response is an alternative behavior that occurs in place of the habit behavior and supplants the habit behavior. The occurrence of the habit or an antecedent to the habit serves as a cue for the client to engage in the competing response as an alternative behavior. The therapist and significant others reinforce the correct use of the behavior. Whether the competing response supplants the habit behavior or punishes the habit behavior is not clear. It is possible that one or both processes are operating to decrease the habit behavior in any particular case.
Research has shown that competing response training is effective in reducing motor tics such as head shaking, eye blinking, facial tics, shoulder jerking, and head jerking; nervous habits such as nail biting, hair pulling, thumbsucking, chewing on clothes, scratching, and eye rubbing; and stuttering in children and adults. Competing response training has also been used to reduce outbursts of anger during athletic competition and to decrease rumination (regurgitation and rechewing of food) following meals.
Research has also shown that competing response training may not be effective with young children and with individuals with mental retardation. The ineffectiveness of competing response training may be due to the fact that children or individuals with disabilities are less motivated to change their behavior. They may not be distressed by the behavior and, therefore, may not express a desire to stop the habit and may not comply with the treatment procedures.
Research by Miltenberger and colleagues has shown that competing response training is effective for a variety of habit disorders. For example, in 1985, Miltenberger, Fuqua, and McKinley showed that both habit reversal and competing response training were effective in decreasing motor tics. In 1985, Miltenberger and Fuqua also showed that competing response training was effective for nervous habits. In 1993, Joel Wagaman, Mil-tenberger, and Rich Arndorfer showed that competing response training was an effective treatment for stuttering in children. In addition to these studies, other research has demonstrated the effectiveness of competing response training for habits, tics, and stuttering.
Research also suggests that, in some cases, social support procedures or other operant contingencies may be necessary to ensure the effectiveness of competing response training, especially with children. For example, in 1999, Ethan Long and colleagues used differential reinforcement and response cost procedures with children and individuals with mental retardation after competing response training by itself was ineffective in the treatment of thumbsucking, nail biting, and hair pulling. Social support or other reinforcement contingencies may help promote the consistent use of the competing response by the client with the habit disorder. When the competing response is used consistently each time the habit behavior occurs, competing response training is more likely to be effective.
Keith was a 12-year-old male who exhibited two motor tics: a mouth tic in which he pulled back the corners of his mouth, stretched his mouth open, and stuck out his tongue; and an eye-blinking tic involving hard eye blinking. Keith was diagnosed with Tourette's disorder and attention deficit hyperactivity disorder and was receiving sertraline (25 mg) daily. He received competing response training as part of a research project completed by Doug Woods, Ray Miltenberger, and Vicki Lumley in 1996.
The therapist first established a recording plan in which Keith was videotaped for 20 minutes in his home two times a week to evaluate the occurrence of tics before and after treatment. The occurrence or nonoccur-rence of both tics was recorded in continuous 10-second intervals, and a percentage of intervals with tic occurrences was calculated for each tic. Competing response training was implemented with Keith for his mouth tic in a one-hour treatment session and two 20-minute booster sessions scheduled one week apart. After improvements were seen in the mouth tic, the same treatment regimen was administered for the eye-blink tic.
The therapist began with awareness training to teach Keith to become aware of each occurrence of the tic. Keith described the movements involved in the tic and demonstrated the tic for the therapist as part of the response description procedure. Keith was not able to identify any antecedents to his tics. As part of the response detection procedure, he then observed himself on videotape and pointed out each occurrence of the tic that he saw on the tape. After identifying occurrences of his tic on tape, Keith practiced identifying each instance of the tic that occurred in the session as he talked with the therapist. The therapist praised him for correctly identifying the occurrence of the tic and pointed out any time a tic occurred that Keith failed to recognize.
After Keith was reliably identifying each occurrence of his tic, the therapist initiated competing response practice. The competing response for Keith's mouth tic involved pursing his lips for one minute. This behavior was chosen because it was incompatible with the tic and was an inconspicuous behavior that Keith could engage in whenever the tic occurred. Keith was instructed to engage in this competing response any time the tic occurred or when he was about to engage in the tic. After describing the competing response and delivering instructions to use it contingent on the tic, the therapist had Keith practice the competing response in the session. Each time that Keith engaged in the tic and then immediately engaged in the competing response, the therapist provided praise. Each time Keith engaged in the tic and failed to use the competing response, the therapist provided a reminder to use the competing response. Competing response practice continued until Keith had correctly identified 10 to 12 instances of the tic in the session with praise from the therapist.
The therapist also instructed Keith's parents to praise him for using his competing response and prompt him to use the competing response if he engaged in a tic and failed to do so. The initial session ended with the therapist instructing Keith to use his competing response contingent on the tic in all situations outside of the session and instructing the parents to provide praise and prompts at appropriate times outside of the session.
In each of the two booster sessions, the therapist reviewed the treatment components with Keith and his parents and had Keith practice the competing response contingent on instances of the tic in session. Keith was encouraged to use the competing response consistently outside of the session and was reminded that consistent use of the competing response would produce the best results in reducing the frequency of his tic.
After Keith's mouth tic decreased from a baseline mean of 26% of observation intervals to less than 3% following the use of competing response training, the same procedures were implemented with the eye-blink tic. The competing response for the eye-blink tic involved a controlled blink every 3 seconds for a total of 15 seconds. The eye-blink tic occurred in 21% of observation intervals before treatment and was reduced to less than 3% of intervals after treatment.
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