HRT (Habit Reversal Training) is a proven behavioral therapy for reducing tics associated with Tourette Syndrome. This treatment is also effective in the treatment of problematic behaviors associated with impulsive control disorders, such as trichotillomania. Tics, Tourette syndrome, and trichotillomania tend to start especially in children and are accompanied by other psychiatric disorders such as anxiety disorders. Therefore, a child-adolescent or adult psychiatrist should be supported with additional techniques for treatment. HRT can also be effective in correcting many repetitive behaviors from rhinotillexomania, onychophagia, and Dermatophagia.
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.
Many patients and relatives say: ”I am not even aware. /I find myself doing this… ” And show that they are not aware of their behavior and the need for relaxation. When they postpone these behaviors or try not to do them, one can understand the distress. Awareness training is beneficial for increasing attention to tic or other problem behaviors. Thus, the self-control skills of the affected person develop better. This training takes place in several steps. 
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.
Habit Reversal Training Steps
On the contrary, there are four main components of habituation training. These components are awareness training, counter-response development, motivation, and skills dissemination. These components will be briefly explained below.
1- Awareness Training
The first task of the therapist is to inform the patient about the situation and ask them to cooperate.
Mindfulness training is geared towards increasing attention to tics or other problem behaviors. Thus, the self-control skills of the person affected by the negative behavior are increased. 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: Each time the person does the problematic behavior (eg plucking eyelashes, plucking skin, pulling hair) by looking in the mirror, describe the moment in detail.
Step 2: The therapist and patient agree that the therapist will tell the patient that every time a tic or impulsive behavior occurs. The therapist provides feedback to the patient over and over again until the patient notices any tics or impulsive behaviors.
Step 3: The patient is trained to identify the warning signs just before the tics or impulsive behaviors occur. These warning signs can be impulses, feelings, sensations, or thoughts.
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.
2- Creating an Opposite Response:
Once the patient has acquired sufficient skill in recognizing tics or impulsive behaviors, the next step is to create an opposite response to replace old tics or impulsive behaviors. Generally, the counter-response is acceptable to tic or impulsive behavior, and it is preferable that this behavior lasts more than a few minutes. For example, nail files for a child who eats nails, chewing gum for a person with lip movements, are behaviors that can be replaced.
In order to prevent recurrence of tic and impulsive behaviors, the patient can make a list of problems arising from these behaviors. Parents or relatives of the patient can also support and appreciate the patient for their success so far. It may also be useful to show others that they can suppress tic or impulsive behavior. It should be noted that every positive step is a very important step for treatment.
4- Dissemination of New Skills
In this part of the treatment, patients are asked to practice new skills they have acquired in many settings beyond what they have achieved until this point. For example, suppressing tics in a safe therapy environment is a relatively easy task, but the same skill should be demonstrated while studying, alone, at work, and in other settings.
On the contrary, Habit Reversal Training is practiced by different therapists as described above, with some minor differences. The treatment is usually administered in eight sessions and can be integrated into current cognitive-behavioral therapy for other mental problems.
Dr. Halil Kara (Child and Adolescent Psychiatrist)
Last Updated on November 5, 2021 by Patric Johnson