Mindfulness-based interventions have demonstrated efficacy for a wide range of clinical concerns and populations. Mindfulness-based Intervention for Tics (MBIT) is a recently developed brief, online group intervention for adults with tics. Preliminary evidence suggests that MBIT is feasible, acceptable, and safe. Symptomatic improvements compare favorably with those associated with Comprehensive Behavioral Intervention for Tics, the first-line behavioral treatment for tics. Additional research is necessary to confirm these findings, identify mediators and moderators, directly compare MBIT to existing treatments, and expand the intervention to children and adolescents.
Key points
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Mindfulness-based Intervention for Tics (MBIT) is a brief, online group intervention focused on 1) building mindful awareness of premonitory urges, tics, and contextual factors that influence tic severity, 2) developing the capacity to notice, sooth, and allow premonitory urges, and 3) the cultivation of kindness and self-compassion.
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MBIT is a promising, safe, accessible treatment option for adults with tics.
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When first-line behavioral treatments (ie, Comprehensive Behavioral Intervention for Tics) are ineffective or inaccessible, clinicians could consider MBIT or another mindfulness-based approach as a reasonable alternative.
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Additional research is necessary to confirm preliminary outcome data, identify mediators and moderators, directly compare MBIT to existing treatments, and expand the intervention to children and adolescents.
Introduction
Over the past 4 decades, our field has witnessed an explosion in research on the physical and mental effects of mindfulness practices, a rapid integration of mindfulness-based concepts into mainstream psychotherapy, and the proliferation of mindfulness-based interventions (MBIs). Although some have argued that the rate at which MBIs have been adopted has outpaced the scientific evidence, , mounting evidence does suggest that MBIs can be beneficial for a wide range of clinical concerns and populations via multiple hypothesized mechanisms.
Over the past 15 years, our team has been developing an MBI for adults with Tourette syndrome or persistent tic disorder, which we will collectively refer to as TS. In this article, we aim to (1) describe the intervention in its current form, (2) review the existing evidence in support of this approach, (3) conclude with a discussion of remaining questions and areas for future investigation.
Mindfulness-based intervention for tics
Mindfulness-based Intervention for Tics is a short-term, online group intervention. Many of the teachings and practices in MBIT are drawn from Mindfulness-based Stress Reduction (MBSR ) and Mindfulness-based Cognitive Therapy (MBCT). Like these well-established MBIs, MBIT aims to promote a present-moment focus, an approach-oriented and decentered stance toward experience, improved attentional, emotional, and behavioral self-regulation, and the cultivation of kindness and compassion. The intervention is also specifically tailored to individuals with TS, with a focus on building mindful awareness of premonitory urges, tics, and the contextual factors that influence tic severity, developing the capacity to notice, sooth, and allow premonitory urges, and the cultivation of kindness and self-compassion toward the experience of ticking and having a tic disorder, specifically. Additionally, because some individuals with TS have struggled to engage with traditional mindfulness programs because of pervasive assumptions that meditation is characterized by stillness and quiet, states that often elude people with TS, we aim to dispel these assumptions and emphasize that although stillness and quiet are often by-products of meditation, they are not necessary conditions for the practice. All movements and sounds are welcomed throughout the program.
In what follows, we present an overview of MBIT’s structure and aims followed by a session-by-session summary of content and practices. See also Table 1 for a summary of weekly aims and practices.
| Week | Theme | Aims | In-session Practices | Home Practices |
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| 1 | What is Mindfulness? |
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| 2 | Noticing Body & Mind |
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| 3 | Noticing Urges & Tics |
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| 4 | Soothing Urges |
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| 5 | Befriending urges and cultivating self-compassion |
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| 6 | Allowing Urges |
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| 7 | Making Choices |
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| 8 | What’s Next? |
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Program Structure and Format
MBIT currently consists of 11 group videoconference sessions over a 4-month period. The first eight 90-min sessions represent the core of the intervention and are offered weekly for the first 8 weeks. Between the weekly videoconference sessions, participants are given daily home practices (eg, guided meditations, awareness-building activities) that are accessible via OC-Go, a free mobile app designed to provide easy access to home practice exercises and tools.
The remaining three 60-min sessions are focused on review and integration of the ideas and practices learned in the first 8 weeks. These booster sessions are offered at 2 weeks, 4 weeks, and 8 weeks after completion of the eighth session.
Groups typically consist of 1 clinician and 6 to 8 adult participants. Although the group format is traditional for MBIs, it is only recently that group treatments have been examined in TS. , Indeed, some individuals with TS may be reluctant to engage in a group treatment for fear of tic contagion. In our experience, however, the group format is an integral part of the intervention. Many of our past participants have not had the opportunity to know other individuals with tics and report feeling uniquely understood and supported by the other members of the group. Tic contagion has not been an issue in our previous trials.
Session Structure and Format
Sessions typically begin with a brief mindfulness practice (eg, gentle stretching), followed by review of home practice. In reviewing home practice, we aim to provide participants with an opportunity to reflect on their experiences, what they have learned, and also obstacles to engaging in practice. Participants also often learn from others’ experiences and challenges.
Following home practice review, the sessions focus on the teachings and practices related to the theme of the session. Psychoeducation and formal practice are interwoven to provide participants with a mix of understanding and experiential exploration of the concepts and skills being introduced. Discussion is encouraged throughout every session to facilitate understanding, learning from others’ experiences, group cohesion, and connection.
Sessions generally conclude with a discussion of home practice for the coming week and an opportunity for questions. Home practice is regularly emphasized as an important means of integrating and applying the teaching and practices learned in session.
Program Aims
The course begins with an introductory phase (sessions 1–2) focused on introducing mindfulness, presentation of the treatment rationale, and the establishment of a warm and inclusive group dynamic. In introducing mindfulness, we aim to give participants a clear idea of what mindfulness is, dispel common myths about mindfulness, and provide participants with an experiential understanding of mindfulness through foundational practices such as the mindfulness of the senses, mindfulness of the breath, the body scan, and mindfulness of thoughts and emotions. We introduce core attitudinal foundations of mindfulness including curiosity, non-judgment, and kindness. We also introduce core attentional control skills through focused attention practices (ie, practices that involve sustained attention to an anchor (eg, the breath)), and practices that encourage the adoption of a decentered, observer perspective on events of the mind (eg, imagining that thoughts are like clouds in the sky or leaves on a stream). These practices intentionally do not focus directly on urges or tics and are instead designed to provide participants with foundational knowledge and skills that they can later apply to working with urges and tics. Sessions 1 to 2 also focus on providing participants with a firm understanding of the treatment rationale. To do this, we begin by providing psychoeducation about tic disorders, with a particular focus on how tics can become reinforced every time they successfully, but temporarily, get rid of the urge to tic. We then introduce the idea that mindful acceptance of urges might allow participants to interrupt this cycle, resulting in fewer tics, less discomfort, and greater quality of life. Finally, sessions 1 to 2 are an important opportunity to form a supportive and inclusive group environment through the sharing of group norms & confidentiality agreements, personal histories and motivations, and by identifying experiences common among people with tics. Discussion and reflection are encouraged in these sessions and throughout the intervention.
The second phase of the intervention (sessions 3–6) focuses on the direct application of mindfulness to urges and tics. This is primarily accomplished through an interweaving of traditional practices (eg, mindfulness of emotions meditation, mindful movement, a self-compassion meditation, the mountain meditation) with a series of “Riding the Wave” meditations designed specifically for individuals with TS. These “Riding the Wave” meditations each teach specific ways of noticing and working with urges to tic. Riding the Wave 1: Noticing urges and tics (session 3) aims to facilitate non-judgmental awareness of premonitory urges as they arise. Participants are encouraged to observe their urges to tic with fresh eyes, noticing the quality, location, duration, and intensity of urges as if they had never before experienced them. Riding the Wave 2: Soothing urges (session 4) aims to provide participants with specific strategies (eg, focusing attention on a neutral anchor spot, using imagery to visualize discharging the urge to tic from the body, or breathing into the urge to tic) for working with the premonitory urges and the discomfort associated with them. Participants are encouraged to explore all of these options and nonjudgmentally observe what happens to the urge and tics in response. Riding the Wave 3: Befriending urges (session 5) aims to cultivate a welcoming and kind stance toward premonitory urges and the self. Participants are encouraged to stop struggling against the urges and explore what it feels like to befriend them. They are also encouraged to adopt a self-compassionate stance toward themselves. Finally, Riding the Wave 4: Allowing urges (session 6) aims to encourage a steady decentered, non-reactive stance toward premonitory urges, allowing them to arise and subside without intervention.
The third phase of the intervention (sessions 7–8) focuses on using what participants have learned about the contextual factors that influence their tic severity to make behavioral choices that reduce stress and promote ease (eg, changing one’s schedule to minimize stress, talking about their tics with family members or coworkers), the integration of mindfulness practices into one’s daily life, and navigating the transition to independent practice as the weekly sessions come to an end.
The final phase of the intervention (session 9–11) focuses on review and application of the previously introduced ideas and practices. Participants are given ample time to reflect on and discuss how they are applying the ideas and practices in their daily lives and to set goals for the coming weeks. Suggestions for overcoming common obstacles to implementation are also provided.
Session-By-Session Summary
Session 1: what is mindfulness?
The session begins with a warm welcome, as well as a discussion of confidentiality and norms for group participation. Participants then introduce themselves and are encouraged to identify shared experiences. The clinician then presents information on what mindfulness is and dispels common myths about mindfulness. Next, participants are led in a mindfulness of the senses practice, a common exercise for introducing mindfulness to beginners. In the exercise, participants are encouraged to explore their environment using all 5 senses with a beginner’s mind (ie, as if they had never encountered the place before). Psychoeducation about tics and the treatment rationale is then provided. Finally, participants are led in a brief mindfulness of the breath practice. Home practice consists of completing a daily guided mindfulness of the breath meditation, mindfully observing one’s daily activities (eg, tooth brushing, washing the dishes), and changing 1 habit (eg, drive to work a different way, sit in a different chair for dinner).
Session 2: noticing body and mind
The session begins with brief mindful movement and a review of home practice. Participants then complete the body scan, a foundational practice that encourages mindful attention to sensations in the body and the modulation of attention to manage difficult or painful sensations. Information about common misconceptions regarding the fixed nature of neurodevelopmental disorders, like TS, and the ways in which meditation may alter psychological and neurobiological processes is provided. Finally, participants complete a mindfulness of the body, breath, and thoughts meditation that introduces the concept of decentering, or taking a somewhat removed perspective on one’s inner experiences. Home practice consists of a daily body scan and monitoring the external contextual factors (eg, activities, people, location) present when tics occur.
Session 3: noticing urges and tics
The session begins with brief chair yoga and a review of home practice. Participants are then led in a mindfulness of the body, breath, thoughts, and emotions meditation that extends the concept of decentering to more challenging inner experiences (ie, emotions). In anticipation of the first tic-specific meditation, the therapeutic rationale is reviewed, and participants are encouraged to adopt an open, curious, and non-judgmental approach to this new way of working with urges and tics. They are then led in the Riding the Wave 1: Noticing urges and tics, which encourages them to notice and explore the premonitory urge and tics with a beginner’s mind. Home practice consists of a daily Riding the Wave 1 meditation and noticing the internal contextual factors (eg, emotions, sensations, thoughts) present when tics occur.
Session 4: soothing urges
The session begins with a review of home practice. Participants are then led in mindful standing stretches that encourage mindful attention to sensations in the body in motion and provide relief for muscles that may be tight or fatigued from ticcing. Information about the continuum of behavior from reflex to conscious choice and the difference between suppression and mindfully allowing the urges to subside is then provided. Participants are then led in Riding the Wave 2: Soothing urges, which guides them in modulating their attention and/or employing one of several soothing strategies to manage urges to tic. Home practice consists of completing a daily Riding the Wave 2 meditation and recording observations about the practice.
Session 5: befriending urges and cultivating self-compassion
The session begins with gentle stretching and a review of home practice. Participants then complete a self-compassion meditation that, based on the work of Neff and colleagues, encourages the recognition of suffering, acknowledgment that suffering is part of life, and the extension of kindness to oneself. The importance of kindness and self-compassion in one’s daily life and one’s attempts to respond differently to these deeply ingrained patterns is emphasized. Participants next complete the Riding the Wave 3: Befriending urges, which facilitates the adoption of a welcoming and kind stance toward premonitory urges. Home practice consists of completing a daily Riding the Wave 3 meditation, recording observations about the practice, and noticing pleasant events as they naturally occur.
Session 6: allowing urges
The session again begins with self-guided mindful movement and a review of home practice. Participants then complete the Mountain Meditation, a practice that uses imagery to encourage a grounded, steady, observing presence in the midst of ever-changing experiences and circumstances. Information about decentering and identity as they relate to ticcing and having a tic disorder is also provided. Participants then complete Riding the Wave 4: Allowing urges, which encourages a decentered, nonreactive stance toward urges in which they are allowed to arise and subside without intervention. Home practice consists of a daily Riding the Wave 4 meditation, recording observations about the practice, and noticing activities that are nourishing or depleting.
Session 7: making choices
The session again begins with self-guided mindful movement and a review of home practice. Guidance regarding the application of mindfulness to one’s everyday life is provided, and participants are encouraged to consider behavioral changes that might lead to reduced stress and/or a greater sense of ease in their lives. Participants are then led in a goal-setting exercise regarding a behavioral change their would like to make using a mental contrasting and implementation intention framework. In service of supporting independent practice once the weekly sessions end, participants are then given time to complete a guided meditation of their choice using a library of prior practices available in OC-Go. Finally, participants are guided in developing a detailed, personalized home practice plan for the coming week.
Session 8: what’s next?
The session begins with a brief self-guided practice and a review of independent home practice. Participants then complete an open awareness meditation that integrates many of the prior teachings and practices. A review of the entire program is then provided before participants are then led in an exercise intended to help them reflect on their experiences in the program and acknowledge their efforts throughout. Finally, participants are presented with a rationale for sustained practice and given the opportunity to create a detailed, personalized plan for continuing their mindfulness practices in the 2 weeks before the first booster session.
Sessions 9-11: how do we keep going?
Booster sessions begin with a mindfulness practice followed by an in-depth discussion of home practice that both acknowledges goals met and identifies challenges and obstacles. Participants are encouraged to continue adopting a curious, non-judgmental stance toward their own efforts to sustain their practice. They are then supported in developing a plan for continued practice between booster sessions. The final booster session also includes exercises to provide participants with a sense of closure and an opportunity to say goodbye to members of the group.
Review of current evidence
The first direct examination of an MBI for TS was a small open trial of Mindfulness-Based Stress Reduction (MBSR) specifically adapted for individuals with TS. In this 8-week program, termed MBSR-tics, our research team drew heavily on the original MBSR protocol, but modified the intervention to include psychoeducation specific to tics, a tic-specific meditation, and mindfulness practices designed to increased awareness of the contextual factors (eg, emotions, activities, social pressures) that influence tic severity. MBSR-tics was offered in 8 weekly 2-hour in-person group sessions and one 4-hour in-person weekend retreat. Assessments were completed by an independent evaluator at baseline, post-treatment, and 1-month follow-up. In a sample of 18 participants ages 16 and over, MBSR-tics was both feasible and well-received. Seventeen of the 18 participants completed the intervention. The participants reported high levels of satisfaction with the intervention on the Client Satisfaction Questionnaire (CSQ) and in qualitative feedback. Participation was also not associated with any serious adverse events. From pre-treatment to post-treatment, participants reported significant increases in self-reported mindfulness as measured by Five Facet Mindfulness Questionnaire(FFMQ) and significant reductions in both tic severity (20.2%) and tic-related impairment (38%) as measured by the Yale Global Tic Severity Scale (YGTSS). Most participants (58.8%) were rated as “much improved” or “very improved” on the Clinical Global Impression-Improvement (CGI-I) scale at the end of the program. Improvements were also maintained at 1-month follow-up. Increases in self-reported mindfulness positively correlated with reductions in tic severity, supporting the idea that mindfulness training might account for the symptomatic improvement.
Building on these initial findings, Gev and colleagues (2016) next examined the effects of a mindfulness-based approach to managing premonitory urges and tics in youth with TS. The single-session experimental study included 45 participants, ages 8 to 17, who underwent three 2-min conditions: a free-to-tic baseline, a tic suppression condition, and an urge acceptance condition. In the free-to-tic baseline, participants were asked to monitor the frequency and intensity of their urges to tic while ticcing freely. In the tic suppression condition, the participants were asked to monitor the frequency and intensity of their urges to tics while trying as hard as possible to suppress their tics. In the urge acceptance condition, the participants were asked to monitor the frequency and intensity of their urges to tics while nonjudgmentally observing the urges. They were encouraged to imagine that the urges were soap bubbles leaking out of their bodies and to not attempt to argue with the urges, avoid them, or make them go away. In all 3 conditions, the participants also provided a rating of the discomfort associated with the urges. Tic frequency was assessed via video recording. Both the urge acceptance and tic suppression conditions resulted in comparable reductions in tic frequency compared to the free-to-tic baseline. However, urges were significantly less frequent, intense, and associated with less discomfort in the urge acceptance condition relative to the free-to-tic condition. In contrast, the frequency of urges did not decline, and the intensity and discomfort of urges increased in the tic suppression condition relative to the free-to-tic condition. These findings suggest that mindful acceptance of urges can produce tic reductions comparable to suppression while reducing the aversive impact of urges. This study further supports the potential therapeutic benefits of a mindfulness-based approach to managing urges and tics. It is also the first study to directly compare a mindfulness-based approach to the suppression-based approach that is encouraged in leading psychosocial treatments for tics, Comprehensive Behavioral Intervention for Tics (CBIT) and Exposure and Response Prevention (ERP).
In 2021, our research team continued this line of inquiry by developing and testing an online adaptation of MBSR-tics. By adapting it to be delivered remotely, we sought to increase access to the intervention and minimize treatment barriers commonly associated with in-person intervention. The 8-week intervention consisted of weekly 1.5-h self-guided online lessons, weekly 1-h therapist-guided group videoconferences, and daily home practice. Assessments were conducted by an independent evaluator at baseline and post-treatment. In a sample of 5 adults, aged 26 to 59, the online adaptation was both feasible and well-received. All 5 of the participants completed the intervention with high attendance rates. Satisfaction on the CSQ was also high and nearly identical to satisfaction ratings for the in-person form of the intervention. No serious adverse events were reported. An assessment of qualitative feedback revealed that participants benefitted from cultivating greater awareness of their bodies, minds and tics, experiencing greater calmness through the mindfulness practices, developing acceptance and kindness, as well as opportunities for support and discussion in the group. However, home practice adherence was lower than expected (36.8% completion rate). Self-reported changes in mindfulness per the FFMQ were mixed and modest. Formal assessment with the YGTSS revealed mixed and modest improvements in tic severity and impairment as well. Only 2 of the 5 participants were rated as more than “minimally improved” on the CGI-I. These findings suggested that this online approach, while feasible and acceptable, would need to be further adapted to increase participant adherence, more effectively promote mindfulness, and, in turn, produce more meaningful clinical gains.
Recently, our team published initial findings on this further adaptation of online MBSR-tics (now named Mindfulness-based Intervention for Tics or MBIT). In this pilot randomized controlled trial (RCT), MBIT was compared to online psychoeducation, relaxation, and supportive therapy (PRST). In contrast to the prior study, MBIT no longer included self-guided instruction. All content and practices were offered in 8 weekly live group videoconferences and home practice was supported by audio recordings hosted on a website. PRST was also offered in 8 weekly live group videoconferences that focused on psychoeducation, relaxation, support, and discussion of a range of topics related to coping with tics (eg, healthy habits, relationships and communication, self-esteem). A total of 28 adults with TS began treatment. All participants in the MBIT condition and all but 1 in the PRST condition completed the treatment. MBIT was associated with significantly greater reductions in tic severity (d = .85) and tic-related impairment (d = .99) than PRST from baseline to post-treatment. Approximately 69% of the participants in MBIT were deemed “very much improved” or “much improved” at post-treatment per the CGI-I, which was significantly higher than the 13% who received the same rating in PRST. Similar to the prior studies, , no serious adverse events were reported. Data from the follow-up period revealed that although MBIT continued to offer more benefit relative to PRST, the gap between the 2 interventions narrowed suggesting that the intervention could do more to facilitate sustained practice and improvement.
Discussion
Empirical support for mindfulness-based interventions for tic disorders is promising and accumulating. Evidence suggests that MBIT, in its current form, is accessible, acceptable, and safe. Preliminary outcome data also compare favorably with the current first-line behavioral intervention for tics, CBIT. For example, in the largest RCT of CBIT for adults conducted to date, CBIT was associated with a mean improvement of 6.2 points on the YGTSS total tic severity score and a response rate of 38.1% on the CGI-I. In comparison, in our most recent pilot RCT, MBIT was associated with a mean improvement of 9.7 points on the YGTSS total tic severity score and a response rate of 69%.
Many questions still remain, however. First, larger trials are needed to confirm these preliminary efficacy findings in larger, more diverse samples. Second, the range of examined outcomes should be broadened beyond tic reduction to include common comorbid conditions and quality of life measures. Given the evidence suggesting that MBIs can be beneficial for comorbid conditions such as obsessive-compulsive disorder, and attention-deficit hyperactivity disorder, we suspect that a mindfulness-based approach has the potential to benefit individuals with TS in myriad ways. Third, we must begin to systematically examine the mechanisms responsible for any clinical improvements. Although mechanistic research with MBIs is challenging, this work is a necessary step toward refining and improving our interventions to maximize their potency. Fourth, should future studies provide continued support for a mindfulness-based approach to managing tics, studies directly comparing MBIs to our current first-line treatments will be necessary to inform treatment recommendations. Such work should also be designed to permit the examination of predictors or moderators of treatment response. This information would substantially improve our ability to provide personalized care for the many, diverse individuals with tics. Finally, this work should be extended to children and adolescents. TS develops in childhood and ideally, future work will allow us to offer this approach to individuals much earlier in the progression of the disorder.
Current Clinical Trials
To our knowledge, there are at least 2 ongoing clinical trials aimed at addressing some of these unanswered questions. The first is a replication and extension of our prior RCT comparing MBIT to PRST in 150 adults with TS ( clinicaltrials.gov NCT06408662 ). In this trial, we aim to (1) test the efficacy of MBIT for reducing tic severity, (2) examine the mechanisms through which MBIT reduces tic severity, (3) evaluate the secondary benefit of MBIT for comorbid mental health conditions and quality of life, and (4) further examine the durability of gains associated with MBIT. A second ongoing trial is an RCT comparing an in-person treatment that combines mindfulness with habit reversal training (MHRT) to traditional habit reversal training (HRT) and psychoeducation with supportive therapy (PST) among 120 children with TS and 40 healthy controls (chictr.org.cn ChiCTR2100053077). The investigators aim to examine the efficacy and neural correlates of MHRT relative to the other 2 treatments. To our knowledge, this is the first treatment trial to examine this approach in children.
Summary
In summary, MBIs, such as MBIT, are being developed and tested for individuals with TS. Preliminary evidence suggests that they are feasible, acceptable, safe, and efficacious. Although further research is clearly needed, MBIT has the potential to meaningful expand the range of treatment options available for individuals with TS.
Clinics care points
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Preliminary evidence suggests that adults with TS may benefit from a Mindfulness-based Intervention for Tics (MBIT).
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MBIT is currently only available within an ongoing clinical trial (NCT06408662). For cases in which participation is not possible or desirable, it is reasonable to suggest that patients with TS explore high-quality traditional mindfulness-based programs (eg, MBSR).
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Clinicians wishing to incorporate a mindfulness-based approach into their clinical interactions could begin by encouraging patients to (1) adopt a kind, self-compassionate stance toward themselves, (2) carefully observe premonitory urges and the relationship between urges and tics, and (3) explore practices for soothing the discomfort associated with urges.
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