Habit Reversal Training: A Powerful Intervention To Improve Mental Health

Habit reversal training, also called habit reversal therapy (HRT), is a widely used tool in psychotherapy for addressing unwanted behaviors. By helping patients learn how to respond to various stimuli in new ways, HRT can allow individuals to unlearn and replace unwanted habits with healthier behaviors. HRT has often been used in treating tic disorders, but it has broader applications as well. 

Below, we’ll explore the history and therapeutic foundations of HRT, what mental health conditions it can be used for, its potential benefits, and what the research says about its effectiveness.

What is habit reversal training (HRT)?

As defined by the American Psychological Association (APA), habit reversal, also called habit reversal therapy or habit reversal training (HRT), is a “therapeutic technique that teaches a client how to stop responding to a previously learned “cue” and learn an alternative, “correct” response to a stimulus.” 

HRT is considered a form of cognitive behavioral therapy (CBT), which is a type of therapy that typically aims to help individuals identify unhelpful ways of thinking and behaving and then alter their thought patterns to reduce or eliminate the associated behaviors. 

Habit reversal was first developed in the 1970s 1973 to treat nervous habits and tics, and it has since been refined and developed as a multi-component behavioral intervention. It has often been used for treating Tourette syndrome and tic disorders, and more recently, it has also been used in treating obsessive-compulsive related disorders. 

What habits can this form of therapy address?

HRT can be used to treat a variety of unhealthy and repetitive behaviors or “habits,” including:

• Nail biting
• Hair pulling (also called trichotillomania)
• Smoking
• Skin picking
• Overeating
• Any other body-focused repetitive behaviors

These behaviors may occur independently or as a symptom of another mental health condition, such as obsessive-compulsive disorder (OCD). Among people with OCD, HRT may be used to try to address disruptive compulsive behaviors.

Does habit reversal training (HRT) work? 

While the delivery of HRT can vary widely depending on a client’s specific diagnosis and behaviors, habit reversal therapy often involves three core parts: awareness training, competing response training, and social support. 

Awareness training

In awareness training, people are typically taught to become more aware of the occurrence of their habits or tics. Simultaneously, they may work on recognizing certain emotions and any external variables that may heighten the urge to perform a habit. 

Competing response training

Then, awareness training is paired with competing response training, in which the therapist instructs the client to identify a new behavior that is physically incompatible with their old habit. Every time the old habit occurs or is about to happen, the patient engages in this new behavior to combat the habit. For example, i: if a patient has a habit of nail-biting, they might hold their hands at their sides and squeeze a stress ball whenever they feel inclined to bite their nails. 

Social support

Awareness and competing response training are typically considered the most active components of HRT, combined with ongoing social support from mental health professionals and loved ones. Members of an individual’s support network can help them identify repetitive behaviors and utilize their competing responses. 

Efficacy of HRT for tic disorders and related concerns 

Research shows that HRT can be effective for a variety of conditions and age groups. Across mental health conditions, HRT is often most effective for diagnoses characterized by any kind of habitual behavior or tics.

Effectiveness of habit reversal training (HRT) for tic disorders

In a systematic review of HRT on HRT in the treatment of Tourette syndrome and other chronic tic disorders, researchers assessed five randomized controlled trials to determine the efficacy of HRT for these health conditions. In their review, they found significant post-treatment reductions in the severity of tics based on data from 353 patients (adults and children), with an average reduction of 32.3%. In other words, in all five studies, they found that “HRT was shown to substantially reduce tic severity.”

A more recent study, published in the journal Expert Review of Neurotherapeutics in 2020, conducted a meta-analysis of 10 randomized controlled trials to examine the efficacy of HRT for individuals with tic disorders. The researchers again concluded that “HRT is effective for the treatment of patients with tic disorders.”

For hair pulling and other behavioral/mental health concerns

Research suggests that HRT can alleviate symptoms of trichotillomania, as well. In a study of children and adolescents, researchers found that hair-pulling behavior was reduced following an 8-week HRT program.   

In addition, in a recent study of HRT to reduce face-touching behaviors during the COVID-19 pandemic, researchers noted the potential of HRT to effectively reduce risky behaviors that contribute to disease transmission. 

In summary, several studies have found that HRT can be effective for both children and adults, with extensive applications for mental health conditions and even public health concerns. 

Mental health benefits of HRT

Beyond the most obvious outcome of reducing tics and other behaviors, HRT may have several benefits for a person’s mental and even physical health, including:

• Reduced stress and anxiety associated with tics and other behaviors. 
• Greater sense of control over one’s body and actions, as well as emotions that may give rise to certain habits.
• Increased confidence in social situations (work, gatherings with friends and loved ones, etc.). 
• Improved performance in school, the workplace, and other contexts previously affected by unwanted behaviors. 

Collectively, these outcomes can enhance a person’s sense of peace and ability to participate fully in everyday life. 

Other treatment options and approaches

As a standalone treatment, HRT can be incredibly powerful and may be the only behavioral therapy needed to manage a person’s symptoms. In some cases, however, a health professional may recommend a combination of HRT with other treatments to optimize a patient’s health outcomes. These might include approaches like comprehensive behavioral intervention for tics (CBIT) or exposure and response prevention (ERP), both of which we’ll discuss below.  

Comprehensive behavioral intervention for tics (CBIT)

As a newer form of therapy for tics, CBIT is largely based on HRT and can be used as a supplement to HRT. CBIT is typically delivered in eight sessions over 10 weeks, beginning by familiarizing individuals with their tic symptoms and “premonitory urges,” or the physical or emotional sense that their tics are about to occur. Then, therapists aim to help them develop competing responses and adjust their daily activities to prevent their tics. 

Similar to HRT, CBIT often includes relaxation techniques and psychoeducation to improve clients’ people’s understanding of their tics., as well as environmental and emotional factors that may aggravate their symptoms. 

Exposure and response prevention (ERP)

ERP therapy is another common treatment for chronic tic disorders. Like CBIT, ERP works by familiarizing individuals with their premonitory urges. However, unlike both CBIT and HRT, ERP therapists teach clients to “endure” the premonitory urge and to resist their tic symptoms, without training them to develop a competing response. 

At first glance, ERP may seem more overwhelming or even scary to someone with a deeply ingrained habit or tic. However, ERP can empower patients people to develop coping skills in response to distressing situations, given that moments of distress and uncertainty are typically unavoidable aspects of life. ERP therapists typically start small and in a safe, structured environment, beginning with low-anxiety situations before progressing to higher-level exposures. 

How online therapy can facilitate behavioral changes

Traditionally, behavioral therapies are delivered in person, but a growing number of people supplement or even replace face-to-face therapy with an online alternative. Plus, for some people who are experiencing disruptive habits that are affecting their daily lives, there might be some aspects of traveling to an appointment and meeting with someone in person that heighten the urge to perform that habit. In these cases, being able to meet with a therapist from the comfort of home may feel like a less intimidating option, and with online therapy, you can do just that. 

Online therapy for hair pulling and other habits

Research has also demonstrated that online therapy can be effective for a variety of concerns, including trichotillomania and skin-picking disorder. A 2022 study examined internet-delivered behavior therapy (I-BT), which included habit reversal as well as other techniques, for trichotillomania and skin-picking disorder. The researchers concluded that the results suggested that “I-BT is a feasible, acceptable and preliminary efficacious treatment” for patients with trichotillomania and skin-picking disorder.

Takeaway

Habit reversal training (HRT) is a therapeutic technique that teaches an individual how to replace an unwanted behavior with a healthier response. It can be used for a variety of unhealthy and repetitive behaviors, such as smoking, trichotillomania, skin picking, and overeating, and it has long been used in treating Tourette syndrome and tic disorders. If you’re interested in HRT for yourself or a loved one, you can connect with a mental health professional in person or online to begin the process of addressing unwanted behaviors. Take the first step toward getting support and contact BetterHelp today.