Self monitoring and intervention for ring fidgeting habit

Habits are said to form when utilizing the same behavior regularly and consistently in a similar situation for the same purpose. They are performed with minimal thinking and little deliberation; and can be considered an automatising of behaviour. While efficiency in cognitive capabilities is achieved; habits cause information to be ignored, never influencing performance of the habit; as outcomes as a result of the habit are overly satisfactory. It has been suggested that good intentions are not acted upon if interfered by the habit; meaning the short term rewards become opposing to long term intentions. It is then that behaviours are identified as ‘bad habits’, habits that involve actions providing positive outcomes in the short term, but causing negative outcomes in the long run; including nervous habits, motor tics and stuttering.

Nervous habits are defined as unchanging, automatic behaviours that do not serve any social purpose. Examples include hand to head habits such as nail biting or hair pulling; oral habits such as lip or tongue biting; or any repetitive movement such as scratching or object manipulation. Hansen, Tishelman, Hawkins & Doepke (1990) and Woods, Miltenberger, & Flach, (1996), suggest that hand to head and oral habits are most prevalent in the general population. In a study of college students, Woods et al. (1996) reported that 15% of students engaged in hair manipulation, 10% nail biting, 22% chewing of their mouth or lips, while 22% reported manipulating objects such as pens or jewelry. Fidgeting is defined as “engaging in actions that are peripheral or nonessential to ongoing focal tasks or events” (Mehrabian & Friedman, 1986); involving engagement in actions, movement or manipulation of one’s own body or implementation of actions onto other objects; and can hereby be categorized as a nervous habit. Woods and Miltenberger (1996) concluded that habits such as hair and face manipulation were present in anxiety- provoking conditions; while object manipulations were recorded when participants felt bored. Three potential explanations exist in relation to how such habits are developed and maintained. Firstly, habits are said to be negatively reinforced by decreasing tension, due to automatic negative reinforcements, such as reduction in anxiety and stress. Secondly, habits provide self- stimulatory advantages, such as increase in concentration or focus, therefore aiding in production of reinforced outcomes. Nervous habits are also hypothesized to represent a group of behaviours that are caused by schedule-induced or adjunctive behaviours occurring as a result of “time-based schedules such as fixed-time or fixed-interval schedules” (Miltenberger, Fuqua, & Woods, 1998), possibly to fill time between reinforces and other behaviours. However, habits do not tend to interfere greatly in a person’s functioning, as in some cases they may help the individual focus, concentrate or feel aroused; but are known to cause annoyance to the individual or those around them. In some cases, where the frequency may become excessive; numerous negative outcomes can be attributed to nervous habits. For instance hand related habits can lead to risk of infection; while others cause negative social consequences, such as little or no social acceptance. It is when habits occur frequently or intensely that treatment is sought.

Several new behavioural technologies have been developed; through the assessment of treatments using group treatment- outcome and single participant designs as well as several case study experiments; with the latter seen inadequate for drawing valid, scientific interpretations. Controlled single and group experiments, specifically those “using repeated, objective measures with reversal or multiple base line designs have been shown to have scientific merit” (Peterson, Campise and Azrin, 1994), detailing impacts of treatments on the behaviour. Such treatments have been effective in reducing the frequency of habit disorders by over 90% and eliminating them in 40 to 70% of the cases (Peterson et al., 1994); with habit reversal treatment (HRT) found to be consistent in demonstrating high effectiveness and applicability to a range of habits.

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Habit reversal involves several components aimed at increasing habit awareness, developing competing responses, building and sustaining motivation and compliance; as well as incorporating operant and anxiety management techniques (Piacentini & Chang, 2005) to effectively treat habits. Azrin and Nunn (1973) successfully treated 12 clients who exhibited habits for up to 7 years, through the implementation of the 4 key stages of HRT: awareness training, competing response training, habit control motivation and generalized training. Awareness training included components such as: response description, where clients are asked to describe the details of the habit behaviour; response detection where therapists reported occurrences of the habit to the participant almost immediately after occurrence; an early warning procedure where clients became aware of the earliest signs of the habit and situation awareness where an analysis was implemented to name high-risk situations where the habit may occur. Competing response practice involved the client developing a short and socially acceptable behavioural pattern opposite to the habit, usually through a shaping technique. In the case of nervous habits involving hands; clients were instructed to “place his/her hands down by the sides, and to clench their fists until they could feel tension in their arms and hands” (Azrin and Nunn, 1973). Motivational procedures such as habit inconvenience and social support procedures were used; with reviews of the inconveniences, embarrassment or suffering experienced implemented; while family members positively reinforced the individual’s efforts when habit free periods was noted. Clients were asked to perform the CR correctly in the presence of a councilor, while also taught a symbolic rehearsal technique, where clients imaged habit eliciting situations, their detection of the habit behaviour and performance of the appropriate CR for a required 15 minutes. Clients were also reinforced and reminded of their habit under more casual situations, and were required to elicit the CR for 3 minutes, a technique known as generalized training. The study reported a significant reduction in habit occurrence of 90% after a single session, with an increase to 99% three months after treatment.

Similarly, Azrin, Nunn, and Frantz (1980) investigated the effects of HRT on habits, comparing it to negative practice; a technique similar to HRT, but different, as the habit was performed for 30 second periods over an hour period, each day until four days after the habit was undetectable; while participants were telling themselves they should not be doing the habit. It was reported that the HRT was more effective, as HRT reduced habits by one third. Woods, Miltenberger & Lumley (1996) reviewed the effectiveness of awareness training, self-monitoring, social support, and competing responses in 4 children. Woods et al. concluded that, while all stages were successful, self-monitoring should be used as the initial stage in treatment, with other components implemented after awareness has been detected. Additionally, the use of anxiety and operant techniques, have also proven successful in treatment of habits. Anxiety management techniques, such as breathing exercises, muscle relaxation and imagery have been implemented as “increases in stress and anxiety lead to concomitant increases in tic frequency, intensity and duration” (Cohen, Friedhoff, Leckman, & Chase, 1992). Although unsuccessful individually, benefits have been detected in multi-component treatments such as HRT. Similarly, operant techniques, in forms of contingency management, “entail the manipulation of environmental contingencies so that tic-free intervals are positively reinforced, and tic behaviors are punished” (Piacentini & Chang, 2005).They should only be used in instances where a clear relationships between the habit and the environmental contingencies are observed. The aim of this study is to suggest an effective intervention or treatment to reduce the occurrence of object fidgeting in a 19 year old female. It is hoped that through the implementation of this HRT, the habit in question is effectively treated, hereby providing the client with a long term solution.

Method

Participant

The participant of this study was a 19 year old Western, middle class, female undergraduate psychology student who expressed interest in reducing the frequency of a nervous habit, specifically the habit of fidgeting in form of manipulation of an object.

Operational definition

‘Fidgeting’, in this instance, was the engaging in one particular action, non-essential and external to ongoing tasks. Focus was primarily upon the manipulation of an object; in this case the action of fidgeting with a ring. Actions involved the individual using their right hand or left hand fingers to turn the ring into a circle around the finger of which the ring was present. The instance where the individual may have been moving the ring back and forth while on the finger was also counted. Taking the ring on and off the finger; meaning the individual took the ring off and put the ring back on was not taken into account. Ring fidgeting can be classified as an excess nervous behavior; that is unwanted, and therefore should be decreased in frequency, duration or intensity. This behavior was monitored due to its relative high frequency in Participant X’s everyday life.

Selection and justification of monitoring method

Assessment of the behavior was achieved through the method of an event recording, self- monitoring method. The participant was asked to record the frequency of the habit over a period of 14 days as well as the time the behavior occurred, when and where it occurred, who was around and what happened before and after the habit was detected. Event recording measures the occurrence, either frequency or duration of a low to medium occurring behavior during a specific time interval. This method was used as event recording has been proven effective when wanting to increase or decrease the occurrence of a habit or behavior, while also allowing the behavior in question to be clearly identified as having a beginning and an end. In this case also the habit did not happen at such an extreme high rate that the event itself was difficult to record. Similarly, a self-monitoring method, while less costly and convenient, could prove ineffective as it is possible the act of self behavioural assessment may actually reduce the frequency of the habit, with the individual becoming highly aware of the behavior; and as a result consciously or subconsciously decrease the act of the behaviour.

Results

Results obtained from the self-monitoring of Participant X’s ring fidgeting habit over the 14 day, self monitoring period are illustrated in Figure 1 below. As the graph illustrates, participant X’s mean of ring fidgeting (M = 3.93) over the 14 day period proves relatively low. A range between extreme scores of 7 was obtained, while the lowest number of fidgets occurred on Day 14 and the highest on Day 7 of monitoring. It is hypothesized that due to the participant’s preoccupied nature, no incidences were recorded on day 14 of monitoring. It is possible that the reason for high detection of fidgets on Day 7 could be as a result of X’s high levels of stress and fatigue and anxiety associated with her university lifestyle. The frequency of the behavior increased for the first three days, decreased for a day, increased for the following three days, reaching its peak on Day 7. The behavior then decreased abruptly, occasionally increasing, before leveling off for two days and finally becoming undetectable by the last day of monitoring. Of all days, day 14 proved to be different to the other days of monitoring, with no detection of the habit recorded.

Contextual

Studying for university exams; recalling facts and information, usually when alone

Working on assignments and essays; mainly when researching or planning, even writing, usually alone

On the train/ waiting for train to go to university in the morning and afternoon- around people

Feeling tired after long day at university or after long day studying; around people and when alone

When not really doing anything; waiting to get home on the train, or waiting for the train

Immediate

Feeling stressed or worried about; exams, too many assignments; a lot to do, little time to do it in

Feeling overwhelmed and stressed about amount of work needed to be done for university- things like assignments, studying for exams

Frustration when not able to recall facts and information for exams

Feelings of boredom when not doing much; usually when knows has much to do- specially when on the train to university or back home; as most of the time it is very busy and cannot do much university work- feels like she is wasting time

Feeling annoyed about what is happening in life, even in the rest of the world (war etc)- annoyed at the fact that she may not be doing enough in regards of her assignment work or studying; some instances annoyance may be due to hearing something on the news or reading about something that she may not agree with

Feeling tired- usually effects the participant in terms of lack of concentration and allows the patient to lose focus on the task

The participant sometimes lacks self-confidence, sometimes feels anxious and uncertain when doing assignment work, university work or when in situations where things seem to go wrong unexpectedly

The participant sometimes experiences feelings of overwhelm, annoyance and frustration when unable to do certain tasks; most prominently task relating to her university career

Believes that she needs to do well at university and therefore is mindful of what she is required to do; must perform well in order to gain excellent qualifications and therefore build a relatively worthwhile career

Knows that her university life depends on her ability to study efficiently; to produce high standard assignments for her psychology courses

Also highly believes that what is happening in the world now is going to affect everyone and everything; including her family, her friends and herself- somehow hopes to make a difference – which may lead again to the pressure which the patient feels when it comes to her career or in this case- how her university exams and assignments (grades) will impact on her ability to get to that level = pressure = anxiety, stress, frustration and feelings of overwhelm

Ring Fidgeting

‘Fidgeting’, in this instance, was defined as engaging in one particular action, non-essential and external to ongoing tasks. Focus was primarily upon the manipulation of an object; in this case the action of fidgeting with a ring. Actions involved the individual using their right hand or left hand fingers to turn the ring into a circle around the finger of which the ring was present. The habit was observed during the participant’s waking hours.

Immediate

Reduction in anxiety and stress levels = feels calmer and peaceful

Reduction in levels of frustration or disappointment

Reduction in boredom = preoccupation- has a distraction from her anxiety provoking thoughts; feels like she is doing something and able to fill time

Increase in ability to recall facts and information for university exams, ability to work efficiently and faster on assignments

Increase in ability to focus and concentrate on the task at hand and make good progress on the task

No reduction in level of tiredness; still reports to feel fatigue

Reduction in self-consciousness

Allows the patient to take time out from her busy life and reflect, possibly clear her thoughts

Long Term

Possible damage to surrounding skin areas

Risk of infection if the behaviour becomes excessive

As a result of above consequence; possible inability to write or type

Possible loss of feeling if the behavior is excessive

As a results of all these, the individual could experience little social acceptance – meaning that as a result of the damage to skin areas, which does not look nice and is not very attractive- people around the individual may never make friends or even maybe marry

This may lead to depression- as such a problems as being cast out of a social groups, or possibly never having a partner or friends can lead to the patient becoming depressed- feeling down, or feeling like everything may pointless and not worth it

Negative reinforcement

Negative reinforcement

Negative Reinforcement

Positive Reinforcement

Positive Reinforcement

Positive Punisher

Negative reinforcement

Positive Reinforcement

Positive Punisher

Positive Punisher

Negative Punisher

Negative Punisher

Negative Punisher

Positive Punisher

As seen in the Table 1 above, participant X is a 19 year old female who has suffered from habitual ring fidgeting for the last year and a half. Historically, X reports the habit to have begun recently; possibly since the commencement of her university life. The behavior may also be as a result of observations, while her busy university lifestyle and lack of sleep may elicit, but not directly cause the occurrence of the habit. Contextually, X’s habit occurs during times when completing university assignments, studying for university tests at home, travelling to and from university or when really not doing anything; and reports feelings of anxiety, stress, worry, annoyance, frustration, fatigue or boredom when performing the behavior. She describes herself as lacking self-confidence, feeling pressured and uncertain at times about her university work, believing that she must perform well, while highly regarding current world events to play a part in her future. X reports that when fidgeting she experiences relief from anxiety, frustration, boredom and self-consciousness; and experiences increased ability to recall facts and information, concentrate and focus and to clear and reflect on her thoughts, but report little change in her level of tiredness. Long term consequences in this instance were not detected; as the client has experienced the habit for a short time. Hereby, based on the immediate consequences it can be said that the relief and increase in abilities which X feels when fidgeting appears to surpass any sort of immediate negative outcome the habit may impose.

Discussion

The aim of this study was to implement an effective treatment to reduce the occurrence of object fidgeting of a 19 year old female. It is hoped that through the implementation of this treatment the habit in question is effectively reduced and controlled by the participant. Frequency monitoring of the habit suggests that ring fidgeting in this case was not severe, as the mean fidgets over the 14 days were relatively low. The participant reports that she feels stressed, worried, annoyed, frustrated, tired or bored when performing the behavior; but reports that as a result she experiences relief from anxiety, frustration, boredom and self-consciousness; as well as increased ability to recall facts and information, concentrate and focus on the task at hand; but reports little change in her level of tiredness. The findings seem consistent with the literature outlined previously. As pointed out by Woods and Miltenberger (1996), nervous habits are prevalent in anxiety- provoking conditions; with object manipulation habits recorded when participants feel bored. In this case, the habit seemed to have been present in both types of situations, with immediate stimuli including feelings of anxiety, frustration and boredom. Overall, it is evident that in this case the habit was negatively reinforced by a decrease in tension, mainly through negative reinforcements, such as reductions in anxiety, stress and boredom. Additionally, the participant also reported self-stimulatory advantages, with an increase in focus and concentration. Nervous habits were also hypothesized to be caused by schedule-induced or adjunctive behaviours occurring as a result of “time-based schedules such as fixed-time or fixed-interval schedules” (Miltenberger et al., 1998). It is possible that X’s habit may be a way to fill in time between behaviours in everyday life and normal reinforces, or be due to the specific stimuli or events. Severe and long term consequences due to the habit could not be detected; but it can be postulated that were the habit to occur excessively, X would possibly be at risk of infection, could experience little social acceptance and as a result possibly depression.

The frequency of ring fidgeting in this case was relatively small, causing no severe damage or impairment in the short term. But because of the possibility of it becoming over excessive, a modified version of habit reversal treatment could be implemented to reduce the habit. This method is proposed for this case as HRT has been successful in decreasing frequency of habits by 90% after implementation, with further increase after treatment. X will be exposed to the 3 stages of HRT: awareness training, competing response training and habit control motivation; as well as operant and anxiety reducing techniques. X will be exposed to response description, where she will be asked to describe and demonstrate in detail the actions and behaviours of the habit; response detection where those around X would report the occurrence of the habit immediately after each occurrence; an early warning system where the client will be taught to be aware of even the earliest signs of fidgeting and finally situation awareness training where the client will be made aware of the high risk situations in which fidgeting may occur. It is known that awareness training would be effective in this case “by making the occurrence of the tic an aversive event (via evaluation or demand characteristics) or that monitoring activities serve as punishers for tic expression” (Piacentini & Chang, 2005), while also reducing frequency of the habit.

Participant X will also be asked to develop a short, acceptable competing response, performed on each occasion when the participant feels the urge to fidget; implemented through shaping. In this case the action of placing her hands down by her side, simultaneously clenching her fists until tension is felt in both arms and hands, could serve as her CR. Shaping allows expression of the habit, while not blocking it but rather weakening the severe aspects of the habit behaviour. Appropriately, the habit could be shaped into more normal behaviours, meaning the CR should be designed to slow down the frequency of the habit, with X not eliciting the habit, but rather something different and appropriate, while also providing X with a different physical expression contingent, still allowing the reduction in negative feelings and positive outcomes. As more control is gained over the habit, the CR “becomes increasingly more forceful with the ultimate goal of greater tic control” (Piacentini & Chang, 2005), and therefore fidgeting would be eliminate.

In addition, several motivation procedures, including habit inconvenience and social support procedures are suggested. Reviews will be conducted in regards to the inconveniences experienced; allowing a breakdown of symptoms, while also enhancing motivation for treatment and serving as a step forward in the acceptance of the habit. Close individuals will also be asked to reinforce each habit free period and correct use of techniques. In addition to the 3 intervention stages discussed; X will also be exposed to several operant techniques, preferably through the manipulation of environmental contingencies. As there is a clear relationship between the habit and numerous contingencies, the participant’s habit free intervals, in the contexts where the habit is most frequent; will be positively reinforced each time; through a rewards system; boosting compliance, while ring fidgets would be pointed out but not rewarded. In addition, strategies of reducing anxiety and stress should be introduced as a clear relationship exists between stress and anxiety triggers and habit frequency. The participant should be taught possible relaxation techniques, such as deep breathing or muscle relaxation, asked to monitor her relaxation levels and instructed to use them before anxiety provoking or stressful events, hereby possibly never eliciting the habit or reducing it greatly.

While the above intervention could be used in its entirety, it must be pointed out that the habit of ring fidgeting is was not overly severe. Results did indicate a relatively low mean for the behaviour, which does indicate the habit as present, but only in relatively low frequencies over 14 days. All stages of the treatment above would have been more appropriate if the participant may have actually experienced severe long term consequences, or possibly more punishers in terms of contingencies. As most of the contingencies proved to be reinforces of reductions in negative feelings, it is possible that anxiety management individually, would serve appropriate, as a clear relationship exists between stress and anxiety triggers and habit frequency. Operant techniques and reinforcement of fixed-habit free periods could also prove successful, as X would learn, after some time that a reward would be given each time the desirable behaviour occurs, in this case the absence of the habit. Awareness training could also have been successful individually, as awareness of the habit to be an aversive event could reduce the habit and also serve as a possible punisher to the participant; hereby decreasing the habit and achieving the goal of this study. Because of the habit was detected as relatively low in frequency, possibly due the fact that X has only experience the habit for a short time; a general HRT treatment would be considered to be inappropriate as such treatment has been successful at treating more long term and highly excessive habits.

Additionally, subjective self-monitoring and SORCK analyses used to analyze the patterns of antecedents and consequent events may not serve as valid in this case. Self monitoring in particular could prove ineffective, with a possibility that the act may actually reduce the frequency of the habit, with the individual becoming highly aware of the behavior; and as a result consciously or subconsciously decreasing the act of the behaviour. Similarly, SORCK analyses were in turn based on self- monitoring and recording, and could be deemed equally as subjective. This study was based on the habit frequency of one subject and not a population of the individuals experiencing ring fidgeting. As this is the case, it is highly hypothesized that the data itself could be rather subjective and non representative of the whole population. Many individuals who self monitor may do so incorrectly and subjectively, as some habits are engaged in without “awareness” and can be missed, while it is also possible that participants could also underestimate overestimate occurences.