Habit Reversal Training: How It Works, Cost, & What to Expect

Habit Reversal Training Components

HRT is a multifaceted method of helping a person escape the endless loop of habitual behaviors. Every habit has its origin, but are often adopted as a means of ineffective coping/soothing mechanisms.⁶ After receiving the fleeting comfort associated with these behaviors, individuals will continually reinforce them, despite the consequences. For example, children afraid of the dark are comforted by security blankets or stuffed animals. Over time, even if the fear diminishes, the child holds onto the item for relief. The five components of HRT serve to systematically break these habits.

The five components of habit reversal therapy are:

1. Awareness Training

Awareness training is the first component of HRT. In this stage, the therapist and client work together to uncover the warning signs that precede a habit. These may include specific thoughts, emotions, and behaviors. Furthermore, situations in which the habit typically occurs are explored. The goal is that a person develops both an internal and external awareness of their behaviors, so that appropriate action may be taken.²

2. Competing Response Training

As part of the second component of HRT, a therapist and client will collaborate on how to implement new, more desirable responses to replace the old one.² For instance, an individual who bites their fingernails for comfort may choose instead to chew gum when triggered. In this case, the client is still engaging in similar behaviors, but the consequences of chewing gum are far less than fingernail biting.

3. Motivation & Compliance

In any therapeutic effort, it is important to proceed intentionally and consistently. As such, client motivation and compliance are necessary. The better someone is able to commit to a treatment plan, the more likely they are to achieve success. In the third phase of HRT, a  therapist and client work to use triggers as a method of inspiring motivation.² Additionally, self-praise and support from others help enhance motivation and compliance.

4. Relaxation Training

Bad habits tend to manifest most frequently when a person is under stress. In relaxation training, various relaxation strategies are utilized to help minimize one’s stress levels.² Mindfulness, meditation, deep breathing, visualization, progressive muscle relaxation, exercise, reading, writing, or listening to music may all prove beneficial. Because self-care activities vary from person to person, this part of treatment is highly individualized.

5. Generalization Training

Just like bad habits, good ones can also form over time with positive reinforcement. Through generalization training, individuals try practicing the therapeutic tactics learned throughout treatment in a variety of situations.² Eventually, these new behaviors become automatic.² Should a stressful situation occur, a person will be more inclined to react in a healthier way.

What Can Habit Reversal Therapy Treat?

HRT was initially developed in 1973 by psychologists Azrin and Nunn to treat nervous habits and tics, such as those associated with Tourette’s syndrome.⁴ More recently, it has been used to treat obsessive compulsive related disorders (OCRD) including trichotillomania (hair pulling) and skin picking behaviors.⁷ HRT can be used to treat other conditions, not just specific formal diagnoses.

Habit reversal training can help with a variety of issues including, but not limited to:

• Tourette’s syndrome
• Tic disorders
• Smoking
• Procrastination
• Obsessive Compulsive Disorders
• Gambling problems 
• Anxiety
• Hair pulling
• Skin picking (excoriation disorder)
• Nail biting
• Thumb sucking
• Depression
• Stuttering
• Excessive fidgeting
• Addiction

Is Habit Reversal Training Effective?

Over the years, many studies have been performed to determine the efficiency of HRT. To date, many major mental health organizations recognize it as an effective form of treatment, including the American Psychological Association, Tourette Association of America, and the National Institutes of Health. Of course, individual results will vary depending on the severity of one’s condition, the complexity of its factors, and individual motivation and commitment.

HRT is generally well accepted by professionals, and is constantly being adapted to better treat a wider variety of behavioral conditions. Since its development, HRT methods have undergone experimental randomized controlled trials, single-subject designs, and uncontrolled group designs.

Here are some research studies that cite the effectiveness of HRT:

• A comprehensive literature review of research demonstrating the efficacy of HRT when addressing tics¹
• Studies showing that patients struggling with nail-biting increased nail lengths by 22% after receiving HRT⁸
• Data concurring that HRT is more effective than a placebo control for body-focused repetitive behaviors⁹
• Statistics showed that children and adults diagnosed with tourette syndrome demonstrated significant post-treatment reduction in tic severity, within a range of 18.3-37.5%¹¹
• A single-case study of a female diagnosed with trichotillomania reporting a significant reduction in hair-pulling behaviors¹²

Risks of Habit Reversal Training

Evidence shows that HRT is more likely to improve a person’s bad habits. However, with any means of treatment, there is the possibility of an adverse reaction within patients. In the cases of HRT, if therapy is not implemented carefully, individuals may replace unhealthy behaviors with even worse ones. For example, replacing nail-biting with smoking cigarettes does not represent improvement. Still, if working with a therapist as intended, this risk should not be of concern.

Criticisms of Habit Reversal Training

HRT criticism is also minimal. However, because diagnosable conditions or undesired behaviors vary between individuals, results will also reflect this. Because of this, HRT may not be the best form of treatment for everyone. More invasive forms of therapy with the addition of medication may be needed to reduce or terminate a person’s negative behaviors. In these cases, therapists may recommend a more appropriate course of treatment. HRT may also be performed alongside other forms of therapy such as CBT or DBT. This can help make for a more effective and comprehensive treatment plan.

Habit Reversal Examples

HRT typically follows a certain progression, despite the specific behavioral condition it is intended to treat. Still, an individual’s personal needs are always considered.

The following are examples of how HRT may be utilized in the treatment of skin picking, tics, and trichotillomania:

Habit Reversal Training for Skin Picking

For the treatment of skin picking, a therapist may begin by asking the client to describe times in which this habit was most prevalent.¹³ Describing the experience aloud may trigger a person to engage in skin picking. Throughout the session, the therapist will call attention to this, so that the client develops a heightened awareness of their behavior. Repeating the process continually helps uncover identifying warning signs, which may be used proactively to prevent future skin picking occurrences. This exercise is conducted until the client identifies every situation that may induce skin picking urges.

Habit Reversal Training for Tics

HRT for tics follows a similar progression in that clients begin treatment by noting the sensations they experience before a tic occurs.¹⁴ Next, competing responses for each tic are identified. For example, a person may engage in certain breathing tactics to help suppress vocal or sniffing tics.¹⁴ From there, intensive training continues until the tic is significantly reduced or extinguished. A client will continue to practice, recognize warning signs, and engage in the competing response methods, both in and out of the therapy setting. It is recommended, especially with children, to enlist a family member or trusted other to provide support.

Habit Reversal Training for Trichotillomania

Out of any other intervention treatment, HRT has received the most empirical support in the effectiveness of treating trichotillomania.¹⁵ For those experiencing this condition, the goal of therapy is to uncover the situations that influence the onset of hair pulling behaviors. These settings are then explored further and subsequently encouraged to be avoided when possible.Over time, replacement behaviors are also incorporated. Rather than pulling one’s hair under stress, they may be encouraged to squeeze a stress ball. This process repeats until a person achieves success.

How to Find a Habit Reversal Therapist

When finding an HRT therapist, begin by searching for one who specializes in this modality. Because HRT is not a traditional method covered in most graduate programs, many therapists obtain specialized training as licensed professionals. Conduct an online search with which you can better review organizations and providers until you find the best fit for you. Beyond the provider’s specialization, it is important to consider fees, location, accessibility, and availability. Using an online therapist directory is a great place to start.

What to Expect at Your First Appointment

Your first appointment with an HRT therapist will begin much like any other therapy session. Prior to meeting your treatment provider, you will likely be asked to complete intake forms, provide necessary payment information, and enroll as a new client. After meeting your therapist, they will conduct a comprehensive biopsychosocial assessment to arrive at a clinical diagnosis. This will help determine the best mode of treatment. Along with HRT, there may also be other modes of therapy integrated into a treatment plan, including medication.

It is important to ensure that you and the therapist establish a healthy rapport. The more you trust your therapist, the more likely you are to follow through with treatment and achieve success. If the therapeutic relationship is not a seemingly good fit, discuss this with your therapist. If issues cannot be resolved, you may want to consider locating another provider. However, be patient, as establishing a working relationship can take time.

Final Thoughts

What you’re struggling with may seem unique to you, but you’re not alone. If you are dealing with behavioral issues such as tics, hair-pulling, skin picking, or any other bad habits, talking to a therapist can make a big difference in how you feel. The healing process takes time, but with motivation and commitment, change is possible. The best investment anyone can make is in themselves and there is no better time than now to pursue treatment.