Habit Reversal Training (HRT)

Although tic disorders are commonly treated by medication, a growing body of research supports psychosocial treatments, particularly habit reversal training (HRT). Used alone or as part of a treatment plan, HRT helps by:

Becoming aware of cues or premonitory urges that indicate the habit or tic is about to happen.
Learning to replace the habit or tic with safe, non-habit forming and incompatible behaviors.

Commonly used techniques demonstrate considerable effectiveness, typically in 8-14 sessions:

Awareness training with self-monitoring. Individuals increase their ability to detect tics or unwanted behaviors and their warning signs. When the behavior is about to happen, they might notice muscle sensations before a tic or mounting muscle tension that prompts, for example, the hair-pulling urge.

Relaxation training. Building on awareness training, individuals learn and apply relaxation and breathing exercises when noticing urges to engage in the tic or habit.

Competing response training. Individuals learn and substitute the undesired behavior with a different, less interfering one. For example, prior to hair pulling, a teen might have a tendency to stroke her hair. Instead, she practices moving her hand from her hair to her ear or squeezing a rubber ball, which help ease stress and occupy her hands.

Social support. The individual enlists social support from family and friends to practice techniques and identify problems caused by the behavior. Prompts, praise and encouragement from friends and family may bolster the awareness training and competing response work.

Generalization of skills. Individuals are encouraged and praised for adapting new skills to everyday life at home, school/work or in other public settings.

HRT with Cognitive Behavioral Intervention (CBIT)

Cognitive behavioral intervention is based on common observations that tics can:

- Get better and worse on their own
- Be in response to a feeling or urge
- Be stopped, at least for a brief time

For this form of therapy to be successful, the child or adult needs to attend therapy training sessions and do homework or practice at home. CBIT actions can be grouped as follows:

Notice situations where tics are worse and better—and try to change the situation to reduce tics.

Break down the tic to watch for and then understand internal urges before the tic starts.

Refuse to give in to the urge/tic by “fighting back” against the urge/tic and delaying doing the behavior.

Practice “competing responses” developed in therapy, such as holding one’s hands down and making a fist or grasping an object.

HRT with Stimulus Control Strategies

Stimulus control strategies are the primary, evidence-based treatments for body-focused, repetitive behavior disorders (BFRB), such as hair pulling, skin picking and nail biting (as well as motor/vocal tics).

Clients are often surprised to learn how many types of situations and factors—emotions, thoughts and/or physical sensations—can trigger these behaviors and how much control they can gain over these behaviors.

Other coping skills—relaxation skills, strategies for managing strong emotions, cognitive therapy skills—are also often a part of these treatments when they address the needs of specific clients.

Along with HRT, stimulus control strategies involve reducing environmental or behavioral triggers. For example, wearing gloves or Band-Aids or covering mirrors to prevent getting the urge to pick; or disposing of tweezers, not watching TV or using hats to cover areas where one is susceptible to pulling hair. Clients can:

- Understand the triggers that cause the behavior.
- Try a competing response to do what counteracts the behavior, using stimulus control strategies and alternative sensory reinforcement.
- Identify a support person to encourage alternative responses.

HRT with Acceptance-Based Behavioral Therapy (ABBT)

HRT also shows promise for treating habit disorders, with growing evidence to support combining HRT with acceptance-based behavioral therapy (ABBT) for BFRBs. ABBT conceptualizes anxiety disorders as developing due to patterns of behavior that may decrease anxiety in the moment, but increase anxiety over time. For BFRBs, behaviors such as hair-pulling may help reduce distress in the short-term, but strengthen the undesired urge and behavior over time.

- Clients are taught to recognize their behaviors and warning signs as they occur—and to perform a competing response.
- ABBT is often accompanied by social support, psychoeducation and function-based interventions

Learn more about Behavior Therapies offered at CFI…

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