Habit reversal training, or HRT, is a behavioural treatment that helps a person recognise an unwanted repetitive action and practise a different response. It is used in care for concerns such as hair pulling and skin picking, and it is also a component of some tic treatments.
The name should not minimise the difficulty as a simple bad habit. Repetitive behaviours can be distressing, partly automatic and difficult to change through intention alone. The aim is practical support and greater choice, not shame or punishment.
What is habit reversal training?
Cleveland Clinic describes HRT as a structured approach involving awareness, a competing response and practice supported by a clinician. The work is tailored to the actual movement or behaviour rather than prescribing one universal replacement.
HRT is not the same as simply keeping busy. A clinician should explain the target, how it is recognised and why the proposed response is appropriate. Ask whether HRT is the whole treatment or one part of a broader plan for your needs.
Understanding the behaviour before changing it
Assessment can explore what happens before, during and after the repetitive action. You may notice some episodes immediately and only become aware of others afterwards. That difference is useful information, not a reason to doubt your report.
For illustration, someone may pull hair while concentrating on a screen and also during a moment of frustration. The practical supports needed in those situations may differ. A treatment plan should examine both instead of assuming that every episode has the same emotional trigger.
Awareness training without constant self-criticism
Awareness work helps identify the behaviour and its early signals. A signal might be an urge, a particular hand movement or a setting in which the action often occurs. The purpose is to create an opportunity to respond, not to monitor yourself perfectly all day.
Discuss how observations will be recorded and reviewed. An incomplete diary can still be useful. Ask for an approach that gives enough information without becoming another source of anxiety. Noticing an episode after it has begun is still different from never noticing it at all.
What is a competing response?
A competing response is an agreed action that makes the target behaviour difficult to perform at the same time. It needs to be safe, practical and suited to the individual. The therapist should demonstrate and review it rather than leave you to improvise a forceful movement.
Ask whether the response is comfortable with your physical health and daily activities. It should not involve pain, restraint or damaging a different part of the body. If an action is awkward or impossible in the setting where the problem occurs, that is a reason to adapt the plan.
Adapting the environment
The circumstances surrounding an episode may offer useful starting points. Consider where it tends to happen, what your hands are doing and whether another activity or arrangement would make the agreed response easier to use.
For example, a person may need a practical reminder during a familiar screen-based task rather than a general instruction to be more mindful. The purpose is to support a skill, not create an environment filled with restrictions. Changes should preserve ordinary life as far as possible instead of making avoidance the only strategy.
HRT for hair pulling
The NHS describes habit reversal training as a commonly used treatment for trichotillomania, or hair-pulling disorder. Work can involve understanding the pattern, practising alternatives and receiving supportive encouragement.
Our hair-pulling treatment guide explains related assessment needs. Hair loss can have other causes, so a clinician may need to examine the affected area. A psychological explanation should not replace assessment of a skin condition or another medical contributor.
What does the hair-pulling research show?
A randomised trial of forty young people aged seven to seventeen compared eight sessions of HRT with treatment as usual. HRT produced greater improvement in hair-pulling measures, and 76% were rated as responders compared with 21% in the comparison group.
This was a small study, and follow-up information was available for fewer participants. The result supports HRT in the population studied without guaranteeing that every child or adult will respond similarly. Ask how your own progress and remaining needs will be evaluated.
HRT for skin picking
NHS guidance on skin-picking disorder explains that CBT may include HRT to improve awareness and develop less harmful responses. It also notes that skin conditions and other concerns may contribute and need attention.
A pilot randomised study of twenty-five adults found greater reductions in skin picking with habit reversal than with a waiting list, including at three-month follow-up. The small sample and comparison condition limit conclusions about long-term effectiveness or superiority to other active treatments.
Nail biting and related behaviours
HRT has also been studied for chronic nail biting. A randomised study involving thirty adults compared habit reversal with a control intervention. Such research is specific to the behaviour and programme examined.
The nail-biting guide describes related support questions. Treatment should focus on harm, distress or interference that matters to the person, rather than trying to remove every harmless repetitive action because someone else finds it noticeable.
Is HRT the same as CBIT?
No. Comprehensive behavioural intervention for tics, or CBIT, includes habit reversal alongside education and other tic-specific strategies. It is a broader treatment package with its own assessment and evidence.
Tics, compulsions and body-focused repetitive behaviours can look similar from the outside but have different features. Ask how the clinician has identified the concern. An approach used for one should not be automatically transferred to another without understanding what drives it and what support is needed.
How HRT differs from exposure and response prevention
Exposure and response prevention is commonly discussed in OCD treatment. HRT instead centres on awareness and a competing response to a repetitive behaviour. A person may need different strategies for different symptoms.
Our OCD treatment guide explains that condition’s care context. Repeatedly checking appearance, pulling hair and carrying out a ritual to reduce a feared threat are not necessarily the same clinical problem. Assessment should guide the intervention rather than the fact that all three involve repetition.
Emotions, urges and additional treatment
HRT can be combined with other approaches where appropriate. A small trial of acceptance and commitment therapy plus HRT reported benefits for adults with trichotillomania compared with a waiting list. Because it tested a combined package, it cannot establish the independent contribution of every component.
Discuss whether anxiety, shame or another difficulty needs additional treatment. ACT or another therapy may address a different part of the plan. Adding approaches should have an explained purpose rather than simply make the programme longer.
Support from other people
A supporter can help with encouragement, but the arrangement should be agreed. Ask what kind of reminder feels acceptable, when it is useful and when you would prefer privacy. Repeated public correction can feel very different from a discreet prompt you have chosen.
For children, adults should support skill practice without making affection or approval depend on symptom-free days. For adults, a partner should not become a constant monitor. The person receiving treatment needs a meaningful voice in how support is offered.
When physical symptoms need care
Skin damage, pain or signs of infection require appropriate medical attention. The NHS also advises assessment when someone eats pulled hair because it can lead to serious complications. Tell a clinician about this even if it feels embarrassing.
HRT does not replace wound care, dermatology or other medical treatment where needed. An urgent physical concern should not wait until a behavioural programme has been completed. The care plan should explain how psychological and physical-health support will be coordinated.
How long does treatment take?
There is no universal number of appointments. Ask about the initial course, practice expectations and review points. Research using eight sessions describes that protocol; it is not a guarantee that everyone will need exactly eight visits.
Review changes in frequency, harm, distress and functioning. A lapse does not erase every gain, but repeated difficulty should lead to reassessment of the plan. Follow-up or maintenance sessions may be appropriate, with a clear purpose and an opportunity to discuss other options.
Choosing an experienced clinician
Ask about the practitioner’s professional qualification and experience with the specific behaviour, not only general CBT training. They should be able to explain the assessment, competing-response selection and how they adapt treatment when progress is limited.
Before ending, agree how to respond to changes in routine or returning symptoms. A realistic plan supports continued practice without expecting constant vigilance. Treatment should help make life more manageable, not replace one exhausting set of rules with another.
Frequently asked questions about habit reversal training
Is HRT just a way of using willpower?
No. It teaches specific awareness and response skills and considers the situations surrounding the behaviour. Difficulty changing does not mean a person lacks determination or needs more criticism.
Can HRT help hair pulling and skin picking?
Research and clinical guidance support its use for these concerns, with outcomes varying by person and programme. Appropriate assessment should also consider physical-health needs and other conditions.
What happens if I do not notice the behaviour?
That is a common issue to explore in awareness training. The clinician can help identify earlier signals and useful environmental cues. Perfect awareness from the beginning is not a prerequisite for treatment.
Can I choose my own competing response?
Work with the clinician to select and test one that is safe and appropriate. A response should not cause pain, involve restraint or interfere dangerously with another activity.
Is HRT suitable for children?
It has been studied in young people, but the approach needs to fit developmental needs and the specific concern. Caregiver involvement should be supportive rather than punitive or intrusive.
What if the behaviour returns?
Review the circumstances and the skills that previously helped. A returning symptom is a reason to seek appropriate support, not proof that treatment was worthless or that lasting improvement is impossible.
Discussing an appropriate next step
A clinical assessment can clarify the repetitive behaviour and the support required. Contact VAYEMA to discuss your concerns and suitable professional expertise.
Sources and further reading
- Cleveland Clinic: Habit reversal training
- NHS: Trichotillomania
- NHS: Skin-picking disorder
- Rahman and colleagues: HRT for hair pulling in young people
- Teng and colleagues: HRT for chronic skin picking
- Twohig and colleagues: HRT for chronic nail biting
- Woods and colleagues: Combined ACT and HRT trial
Related conditions and concerns
These links explain the wider care context. They are not a recommendation that this approach is suitable for everyone with the condition. Use the condition treatment guide to understand alternatives and the role of clinical assessment.