Habit Reversal Training (HRT): First learn it by the book, and then throw it out

Written by: Marie Chesaniuk, PhD

What is Habit Reversal Training (HRT)?

HRT is a behavioral therapy that helps people reduce or eradicate unwanted habits or behaviors. The type of habit in question is often a repetitive behavior that people engage in automatically, without awareness, and are often unhelpful or even harmful in some cases. HRT is used with children and adults.

What conditions is HRT used to treat?

HRT is used to treat excoriation (i.e., skin picking or dermatillomania), hair pulling (i.e., trichotillomania, hair twirling, nail biting, nose picking, thumb sucking, tics and tic disorders (i.e., Tourette syndrome), some cases of Stereotypic movement disorder (SMD) (i.e., usually when these movements become unsafe or self-injurious), and has additionally been applied to social smoking and to reduce the face-touching behaviors that put people at increased risk of contracting COVID.

How does HRT work?

HRT is composed of three major phases: 1) Increasing Awareness, 2) Developing and practicing counter behaviors or competing responses, 3) Contingency management. Because so many of the repetitive behaviors treated with HRT happen automatically or outside the person’s awareness, we begin by increasing awareness of the behavior. To build awareness, a person might do the behavior in front of a mirror and observe and describe it in great detail. Parents may signal to the child that they’re doing the behavior again so that the child can better notice. People may use tracking logs and expand their awareness from the nature of the behavior itself to the triggers that precede it and the consequences that follow from it (e.g., bleeding from skin picking.) 

Once someone becomes more aware of the behavior, they begin the next phase of treatment in which they develop competing responses and counter behaviors. Competing responses and counter behaviors are actions that one does in place of the target repetitive behavior. Competing responses and counter behaviors might use the same muscle groups used during the target behavior (e.g., using a fidget toy instead of picking at cuticles), a different muscle group (e.g., if picking skin on ankle, stand up to get ankle out of reach of hands), or they might use an external aid, like gloves, to interrupt the behavior and enhance awareness. The competing response is practiced whenever the urge to do the behavior is felt as well as when the target behavior is noticed. Competing responses may even be used preventatively in situations that often elicit the repetitive behavior.

Finally, contingency management is used to stay motivated to stick with the new behaviors long enough to build a new habit. This includes praise and rewards for practicing the new behavior.

The gist of HRT is very straightforward. The reality of HRT is often messier.

Throwing out the textbook

Once you know the protocols of HRT, the hard work is being creative and knowing when to stop. Repetitive behaviors, their triggers, and their consequences are all unique to each person. There is no universal counter behavior that works for everyone. In this treatment, the counter behaviors must be tailored to each person, sometimes to each instance of the behavior. For example, some counter behaviors work at home but not at school. Now we need a whole other set for school! The instructions for the treatment don’t do justice to how highly personal and idiosyncratic HRT really is. The collaboration between client and therapist needs to generate far more creative solutions than a simple three part summary lets on.

Furthermore, actually doing HRT brings more to awareness than just a repetitive behavior. Confronting the limits of what you thought you could control and taking responsibility for things you thought were out of your control are some of the hazards of doing this treatment. It can be jarring to learn that your own mind and behavior don’t work the way you thought they did, and this changes how we see and feel about ourselves.

While we’d all love to point to a perfect upward line of treatment progress for every case, the fact is that treatment progress is also messier than a treatment summary suggests. Establishing new habits while fighting against automaticity and the need to manage stress and urges is tough work. It is even tougher to maintain long term. For some people, the third stage of treatment – maintaining motivation – is actually more difficult than becoming aware of repetitive behaviors and generating counter behaviors. Sticking with it long after those early a-ha moments is no easy task. Be brave enough to take a break when you are trying everything and nothing seems to be working. HRT is a marathon, and knowing how to sustain your energy for the long term is all part of the process.

Part of a good HRT therapist’s job is knowing how to ride out those lulls in treatment so that treatment overall continues to be beneficial and sustains motivation for recovery.

HRT is deceptively easy and generic on paper, but in practice it is hard, messy, endlessly unique work that, hopefully, leads not only to healthy coping, but also to a deeper insight into oneself and both one’s theory and practice of control.