Potential treatments for individuals with compulsive leg-shaking
One may have wondered why certain people do peculiar things that may not have left good impressions or have kept people thinking about the reason for that certain act. These behaviours have been termed 'tics' or 'stereotypy', but these terms are not sufficient to describe peculiar behaviours such as continuous handwashing or hair pulling. Previous research such as Carr (1974) and Metzner (1963) have suggested that these behaviours may include an element of neuroticism and they are interlinked with anxiety.
The behaviour being explored in this paper is under the broad label of compulsive neurotic behaviours, which have been defined as acts done by an individual which serve to reduce a certain anxiety that triggers an impulse to do something which is socially unacceptable (Taylor, 1963). Specifically, the behaviour being observed is compulsive leg-shaking and if looked at closely, it constitutes a persistent thought or impulse to move one's legs back and forth when not needed to. The essential nature of this compulsive condition, according to Carr (1974), is that the patient is dissatisfied with her current situation of being unable to control herself from performing this excessive behaviour due to the need to reduce the amount of anxiety she has.
Another way of explaining the etiology of compulsive behaviour can be sourced from Freud's (1895-1909, 1924) attempt to say that such compulsions are a result from having formed conflicts during the toilet training stages of a child or the anal-sadistic stage of an adult. It could be possible that, from a psychoanalytic point of view, the patient's leg-shaking behaviour could have been fixated due to an unresolved matter that she encountered in her early childhood and therefore maintained as there is a stunted development. Furthermore, Adler (1936) proposed that one could have developed compulsive behaviour because of having organismic properties that predispose them to feeling intimidated or inadequate. In turn, those individuals would project strong competitive attitudes in order to attain superiority.
Another way to interpret the patient's behaviour of leg-shaking would be through Dollard and Miller's (1950) contention of defining a compulsive behaviour as a reinforcer that reduces anxiety if it is performed. It should also be noted that this anxiety does not result from childhood traumatic experiences whatsoever. Walton and Mather (1964) established that the concept of a conditioned autonomic drive (C.A.D.), which is the drive that encourages the compulsive behaviour and arouses anxiety; for example, aggression. In relation to this, a motor symptom(s) would develop in order to avoid the anxiety produced by the C.A.D..
Regarding these theories are also therapies that have been proposed to treat individuals who are having problems with compulsion. Firstly, Poole and Bodeker (1975) administered treatment onto a 19 year-old female undergraduate who had a two year history of compulsive rocking before retiring at night and had used a method called time restriction. Apparently, according to Poole and Yates (1975; cited in Poole and Bodeker, 1975), the time restriction method was ideal for controlling unacceptable behaviour that occurred in high frequencies. In this study, they had the female patient learn to manage her compulsions to rock before sleeping by reducing the time she engaged in that particular ritual. In detail, the experimenters allowed her to start from having 25 minutes of rocking each night for 14 consecutive nights. Then after that period, they restricted her time of rocking further to 20 minutes, 15 minutes and 10 minutes subsequently. During her post-treatment follow-up, it was found that the time restriction method had worked effectively on her behaviour as she did not rock before going to sleep except on a few occasions over a six week period. Poole and Bodeker (1975) also discovered that the female patient had developed a "symptom substitution" because instead of rocking, she would tidy up her room for a few minutes before going to bed. Even though a new behaviour developed, the "substitution" appeared to be more adaptive in terms of social standards.
Another treatment that might be closely related to this leg-shaking behaviour would be the aversion-relief therapy by Thorpe, Schmidt, Brown and Castell (1964). The experimenters treated eight people with most of them having sexual identity related problems. In the study, Thorpe et al. (1964) used words related to their maladaptive behaviour as the aversion stimuli which admitted shocks to the patients while words relating to the corrected behaviour were the relief stimuli that had no shocks. For example, a 40 year-old male patient who had homosexual thoughts under the influence of alcohol had the word "homosexual" as the aversion stimuli and the word "girlfriends" as a relief stimuli. In the process of being conditioned to when he was going to get shocked, his behaviour of having homosexual desires during drinking had greatly reduced and had more heterosexually significant relationships in his life after treatment.
An additional potential treatment for the leg-shaking behaviour would be ritual substituition which was achieved by Weiner (1967). Weiner (1967) theorized that if a compulsive behaviour was socially disturbing, the therapist would enforce an alternative ritual upon the patient that was more socially appropriate. In this study, the experimenter had a 15 year-old boy who had compulsive rituals such as washing and dressing which led him to think that if he did not perform those rituals, "something terrible" would happen to his parents or he'll be "drafted into the army and sent to Vietnam and killed" (as cited in Weiner, 1967). Firstly, the experimenters asked for a list of compulsive behaviours that troubled him most and asked him to think of a positive reason for his rituals. Later on, they would implement the established positive reason for his ritual into an instruction that would be repeated by the patient everytime he had checked his locker. The instruction is as follows: "I have checked the lock; and I can now be certain it is locked and everything in the locker is safe and protected; there is absolutely no positive reason for me to check it again; I am now going to walk away from it and go to class" (as cited in Weiner, 1967). After treatment, the patient had successfully eliminated his obsessive rituals.
Lastly, the aim of this study is to suggest an intervention strategy to reduce the frequency of leg-shaking in a 19 year-old female. This treatment plan is meant decrease the compulsive behaviour of leg-shaking as it is considered to be mildly maladaptive but very disturbing at the same time to others. To cause change to this behaviour is important because it will ease the individual into obtaining relaxation from anxiety in a more appropriate way instead of through the manifestation of compulsive behaviour.
Method
Participant
R is a 19 year old female undergraduate at the University of Queensland who has expressed a desire to reduce the frequency of shaking her legs and feet, which has been going on for duration of 4 years.
Operational definition
The behaviour scored was the concentrated shaking of her lower limbs in all sorts of directions when she is not meant to do so. For example, the behaviour would be scored if R shakes her leg or feet in class or while waiting for a bus. However, it would not be scored if R was shaking her legs as part of a warm-exercise in the gym. Furthermore, the behaviour is considered to have occurred when R is aware of the monitored behaviour but does not display it, because R has displayed the intention of doing so. The behaviour displayed by R is seen as an excess entity as the shaking of her legs and feet do not harm nor bring benefit to her. It is a form of reflex that she has been accustomed to which may not bring social desirability to certain people.
Selection and justification of monitoring method
The monitoring method used in R's case was frequency, meaning that R would record every single instance of the behaviour (shaking legs) in the period of observation, which was 14 consecutive days. This method was implemented because the behaviour being monitored was clear and distinct. Also, the behaviour occurred very frequently and gave R the advantage of taking down records easier. The behaviour was meant to be monitored throughout R's waking hours no matter where she was. The frequency monitoring method was beneficial in terms of its simplicity and efficiency in recording clear behaviours but was also drawback as this method carried the risk of overestimating or underestimating the intensity of the behaviour.
Results
The average number of occurrences of R shaking her legs throughout the observation period was 5.36 times a day, with the highest number of occurrences per day being 7 while the lowest was 4.The duration of R's shaking legs behaviour during the monitoring period did not have a fixed pattern as it fluctuated in the number of occurrences, meaning that it increased and decreased on irregular intervals. Towards the end of the monitoring period, some consecutive days (Day 9 and 10; Day 11 till 13) had equal number of frequencies of the behaviour.
As the graph in Figure 1 shows, the frequency of R shaking her lower limbs peaked on day 7 and 14 while it was at its lowest occurrence during day 2, 6 and 8. Other patterns of R's leg-shaking frequencies were firstly from day 2 till 5 where R showed a steady increase in her display of shaking her limbs and a steady plunge from day 5 to 6. Another peculiar pattern in her leg-shaking behaviour was also shown in day 9 to 10 and day 11 to 13 respectively, because those two periods had the same number of occurrences in consecutive days.
Discussion
The aim of this study was to aid an undergraduate female with compulsive leg-shaking behaviour to adopt an alternative that would rid or replace the compulsive behaviour; this was done through a tailored intervention plan. The leg-shaking behaviour that is currently monitored is similar to the above-mentioned disorders as it creates frustration for the individual knowing that it is not an acceptable behaviour. It is also similar in ways that it alleviates anxiety in the individual being treated.
Freud's (1895-1909, 1924) theory of having maladaptive growth in the childhood stage of toilet training can be related to the monitored behaviour as a conflict could have arisen in childhood. This would have led to the patient having a need to use leg-shaking to overcome an unconscious fear or anxiety temporarily. In addition to that, part of Adler's (1936) argument can be applied in saying that the patient's development of this habit may be due to having biologically determined feelings of incompetence and hopelessness. Therefore to rid of these feelings, R shakes her legs to distract her from being eaten up entirely by her real life shortcomings such as failures in exams and assignments. According to Dollard and Miller's (1950) theoretical framework, R's leg-shaking behaviour, which is the compulsive behaviour, would then be seen as a reinforcer that reduces some level of anxiety for her. At the same time, it helps maintain the compulsive behaviour because of its ability to bring emotional benefits to the patient. On the other hand, Walton and Mather's (1964) literature would link the leg-shaking habit as equivalent to the motor symptom as a way to avoid a form of anxiety that has resulted from the C.A.D. of the patient.
According to the SORCK table above, the patient can be seen as to have developed compulsive leg-shaking early in life and is most likely to shake her legs when anxiety or boredom is present. R would also mostly shake her legs when the situation is linked to assignments or simple everyday tasks that do not require her active participation, such as watching TV or waiting for a bus. Despite giving her immediate relief from anxiety and boredom (positive or negative reinforcement), the compulsive leg-shaking brought negative social judgments about her actions (positive or negative punishment).
The treatment plan tailored for R would have to be very comprehensive as the monitored behaviour is continuous and can go unnoticed by the performer. Therefore, treatment sessions would have to go on everyday for at least four hours, which will go on for a period of 30 days. In the treatment plan, the therapists could include a very aversive punishment, so much so that it would make her stop from performing the compulsive act. Another way of getting rid of the leg-shaking would be for R to obtain some form of negative reinforcement, an element that takes away her frustration and anxiety in a more socially acceptable way, both for R and the people around her.
From Poole and Bodeker's (1975) literature on time restriction method in treating compulsive rocking, it would be viable to replicate their method to treat the compulsive leg-shaking as the behaviour is almost similar. In theory, the experimenters can instruct R to minimize her number of times shaking her legs per day based on her frequency records. However, this method may not be as practical as it seems as Poole and Bodeker's (1975) patient only performed the compulsive rocking at night before sleeping. R's current behaviour occurs throughout the day and would be of inconvenience or substantial difficulty in getting herself to constantly restrict herself to shaking her legs to a reduced amount of time since it happens so naturally.
An extra way of treatment would be Weiner's (1967) ritual substitution treatment method. In R's case, the therapists could get her to work out the reason for her shaking her legs, instead of asking her the positive reason for her ritual (since there is none). With her own dictation of what is causing the behaviour, the therapists could get her to decide what necessary steps can be taken to reduce this behaviour. Getting the patient to think for themselves would be a source of self-awareness that could indirectly persuade themselves into eliminating the habit. After that, the therapists would instruct R to act upon her own suggestions and keep record of the occurrence of her leg-shaking during the implementation of her suggestions. Another important component of Weiner's (1967) ritual substitution treatment was that the therapy team involved with the boy was very encouraging and honest with him about what to expect during the progress of the treatment. For example, they frequently told him that he would not always succeed in talking himself out of rechecking his locker and that the failure to do so should not prevent him from trying again the next time. In other words, the team had set up a guideline for him that was both assertive yet less harsh on the patient. It should be the same with R; the therapists should give certain ideas of what she should expect in the duration of the treatment so that she would not feel so much of a failure. This building block would also contribute to the patient's confidence and self determination as it increases R's optimism in eliminating leg-shaking.
The last treatment that can be considered for R's case would be Thorpe et al.'s (1964) aversion-relief therapy. This is where the treatment would most probably be in a lab setting as this treatment includes administration of shocks if one replicates Thorpe et al.'s (1964) treatment plan closely. The current monitored behaviour which is leg-shaking can be the aversive stimuli as a word "leg-shaking" and that maybe the relief stimuli would be the word "still legs" or some other word that implies relaxation. When she is read aloud the words on screen, R would be administered shocks when she reads the word "leg-shaking" and receive no shock at all when she reads out "still legs". Nevertheless, as mentioned before, this treatment would take place in a lab setting which may not always be possible in real world environments. It could also result in R not applying whatever she learned in the lab into the real-life settings and still shake her legs whenever anxious or lonely. On a whole, the optimal treatment plan available for R's compulsive leg-shaking would be Weiner's (1967) ritual substitution method.
It should be noted that the data recorded in the frequency table is somewhat problematic as it is self-report data, which may not be entirely accurate. Furthermore, demand characteristics are always present due to having the participant being very well aware that her behaviour is being monitored. A sample size of one is also not ideal because the generalization of results would be disabled. It would be better to have a larger group go through the treatment together in order to generalize the effectiveness of the therapy to the population.[R1]
References
Adler, A. (1936). Compulsion neurosis. International Journal of Individual Psychology, 2, 3-22.
Carr, A.T. (1974). Compulsive neurosis: A review of the literature. Psychological Bulletin, 81(5), 311-318.
Dollard, J. & Miller, N.E. (1950). Personality and psychotherapy: An analysis in terms of learning, thinking and culture. New York: McGraw-Hill.
Freud, S. (1895). Collected papers. Vol. 1. London: Hogarth, 1924.
Freud, S. (1908). Collected papers. Vol. 2. London: Hogarth, 1924.
Freud, S. (1909). Collected papers. Vol. 3. London: Hogarth, 1924.
Metzner, R. (1963). Some experimental analogues of obsession. Behaviour Research and Therapy, 1, 231-236.
Poole, A.D. & Bodeker, G.C. (1975). Using time restriction to modify compulsive rocking. Journal of Behavioural Therapy and Experimental Psychiatry, 6,153-154.
Taylor, J.G. (1963). A behavioural interpretation of obsessive-compulsive neurosis. Behabiour Research and Therapy, 1, 237-244.
Thorpe, J.G., Schmidt, E., Brown, P.T. & Castell, D. (1964). Aversion-relief therapy: A new method for general application. Behaviour Research and Therapy, 2, 71-82.
Walton, D. & Mather, M.D. (1964). The application of learning principles to the treatment of obsessive-compulsive states in the acute and chronic phases of illness. Behaviour Research and Therapy, 1, 163-174.
Weiner, I.B. (1967). Behavior therapy in obsessive-compulsive neurosis: Treatment of an adolescent boy. Psychotherapy: Theory, Research and Practice, 4(1), 27-29.
