Habit Reversal Training (HRT) and Behavioral Therapy: HRT in 4 Easy Steps

Habit Reversal Training (HRT) is a behavioral therapy for reducing tics associated with Tourette Syndrome that is used most after pharmacotherapies. This treatment is also effective in the treatment of problematic behaviors associated with impulsive control disorders, such as trichotillomania. [ 1 ] Currently HRT may be used to reduce the hand-to-head behaviors that increase the risk of viral infection such as in the Covid-19 pandemic.


Tics, Tourette syndrome, and trichotillomania tend to start especially in childhood and are accompanied by other psychological disorders such as anxiety disorders. Therefore, a child-adolescent or adult psychiatrist should be supported with additional techniques for treatment. Habit Reversal Training can also be effective in correcting many repetitive behaviors from rhinotillexomania, onychophagia, and Dermatophagia.


The goal of Habit Reversal Training is to replace the unwanted habit with a new, more desirable behavior. To do this, HRT focuses on three main things:


1- Identifying the triggers or cues that lead to the unwanted habit


2- Learning new skills or behaviors to replace the habit


3- Increasing awareness of when the habit is occurring.


What is Habit Reversal Training?

Habit reversal training (HRT) is a behavior therapy used to treat habitual behaviors that are unwanted or interfere with daily functioning. The goal of HRT is to help the individual develop new, more positive behaviors to replace unwanted habits. To do this, HRT first works on identifying the cues or triggers that lead to the undesired behavior. Once these triggers are identified, the individual can then work on developing and practicing new response strategies to interrupt and replace the old habit behavior. Over time, with repeated practice, the new behaviors become stronger and more automatic, eventually replacing the old habits entirely. Though it takes effort and commitment, habit reversal training can be an extremely effective treatment for breaking unwanted habits and improving daily functioning.


What is Tourette Syndrome?


Tourette syndrome is a neurological disorder characterized by the involuntary production of sounds and words, known as tics. The most common motor tics are eye blinking and facial grimacing, but other movement may also be involved.


Graph 1: The red line shows the increasing distress before the repetitive behavior and the decreasing distress at the end point. The frequency and tendency increase if this behavior can’t get under control.


Graph 2: If the distress is tolerated and the behavior is postponed, the distress increases first and then gradually decreases (not fast). But if the toleration progress is repeated, it tends to decrease both the frequency and severity of the behavior.


habit reversal training (hrt)


Habit Reversal Training Steps


There are four main components of Habit Reversal Training. These components are awareness training, counter-response development, motivation, and skills dissemination. These components will be briefly explained below.


1- Awareness Training


Awareness training is an important component of habit reversal training (HRT). It involves helping the person identify the triggers, thoughts, and emotions that lead up to the target behavior, and becoming more mindful of these cues in real-time.


For example, if the target behavior is nail biting, the person might be asked to pay attention to the thoughts and feelings they experience just before they start biting their nails. This might include noticing physical sensations, such as an itch or tension, or mental states, such as boredom or anxiety. By becoming more aware of these cues, the person can learn to recognize when they are at risk of engaging in the target behavior and take steps to prevent it.


Awareness training can be done in a variety of ways, such as self-monitoring, mindfulness exercises, and cognitive restructuring. It is an important step in the HRT process because it helps the person understand their own patterns of behavior and develop strategies to change them.


This training is carried out in several steps. These steps are applied during the session and/or given to the client as homework.


Step 1 – Identifying the target behavior: The first step in awareness training is to clearly define the behavior that the person wants to change. This may involve identifying specific behaviors, such as nail biting or skin picking, or more general categories, such as self-harm or impulsivity.


Step 2 – Identifying the triggers for the behavior: The next step is to identify the situations, events, thoughts, or emotions that tend to precede the target behavior. This may involve keeping a log or journal of the behavior and noting any patterns or common themes that emerge. These triggers can be visual, tactile, location wise, or even an activity.



Step 3Developing a competing response: Once the triggers for the behavior have been identified, the person can work on developing a competing response, which is an alternative behavior that can be used instead of the target behavior. This response should be something that is easy to do, and that can be practiced in a variety of situations.


Step 4 – Practicing the competing response: The final step in awareness training is to practice the competing response whenever the triggers for the target behavior are present. This may involve setting reminders or prompts to engage in the competing response, or seeking support from a therapist or other mental health professional.


2- Creating an Opposite Response:


Creating an opposite response, also known as a competing response, is a key component of habit reversal training (HRT). It involves developing an alternative behavior that can be used to replace the target behavior, which is the behavior that the person wants to change.


The idea behind creating an opposite response is that it can help disrupt the automatic pattern of the target behavior and allow the person to develop a new, more adaptive way of responding to triggers and challenges. For example, if the target behavior is nail biting, the person might practice squeezing a stress ball or tapping their foot instead of biting their nails when they feel anxious or stressed.


To create an opposite response, it is important to consider the following factors:



Creating an opposite response is an important step in the habit reversal training process because it helps the person develop new skills and behaviors that can be used to replace the target behavior. It is typically done in conjunction with other components of HRT, such as awareness training and reinforcement, to support the person in making lasting changes to their behavior.


3- Motivation


Increasing motivation is an important aspect of habit reversal training (HRT) because it can help the person make lasting changes to their behavior. When a person is highly motivated to change their behavior, they are more likely to put in the effort and commitment needed to practice the new skills and strategies that are taught in habit reversal training.


There are several ways to increase motivation during the HRT process:



Overall, increasing motivation is an important part of the HRT process because it can help the person stay committed to making positive changes and achieving their goals.


4- Dissemination of New Skills


Dissemination of new skills is an important aspect of habit reversal training (HRT) because it involves transferring the skills and strategies that have been learned in treatment to other areas of the person’s life. This process helps to ensure that the person is able to use the skills and strategies they have learned in a variety of different situations and contexts, rather than just in the treatment setting.


There are several reasons why the dissemination of new skills is important in HRT:



Overall, the dissemination of new skills is an important part of the HRT process because it helps the person to apply the skills they have learned in treatment to their everyday life and make lasting changes to their behavior.


Habit Reversal Training is practiced by different therapists as described above, with some minor differences. The treatment can be integrated into current cognitive behavioral therapy for other mental problems.



Training in Children With Tourette’s Disorder – A Pilot Study [ 2 ]

Brief Review of Habit Reversal Training for Tourette Syndrome [ 3 ]

Reducing risky behavior with habit reversal: A review of behavioral strategies to reduce habitual hand‐to‐head behavior [ 4 ]


References: Dr. Halil Kara (Child and Adolescent Psychiatrist)


Last Updated on December 15, 2023 by Lucas Berg


3 thoughts on “Habit Reversal Training (HRT) and Behavioral Therapy: HRT in 4 Easy Steps”

  1. Hi,

    I was wondering if you have a resource available, in relation to a self help guide for tics for children and young people, specifically Habit reversal therapy or CBT techniques.



  2. How does one find a local therapist who may be trained in HRT and CBT?
    We live in Berkeley and have a young adult daughter who is struggling with dermatophagia.
    thank you!

    1. Hello Robin.

      You can find all certified psychotherapists who are trained in CBT by Beck Institute here. Hope everything goes well for you and your family.

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