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 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 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 3 – Developing 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:

• • The opposite response should be easy to do and easy to remember.

• • It should be something that can be practiced in a variety of situations, including challenging ones.

• • It should be something that is incompatible with the target behavior, meaning that it is difficult or impossible to do both behaviors at the same time.

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:

1. 1. Identifying the benefits of change: By highlighting the positive outcomes that the person can expect to see as a result of changing their behavior, such as improved relationships, increased self-esteem, or reduced stress, they may be more motivated to make an effort to change.
   2. Setting clear and achievable goals: By setting specific, measurable, attainable, relevant, and time-bound (SMART) goals, the person can feel a sense of accomplishment as they make progress toward their goals and stay motivated to continue.
   3. Finding meaning and purpose: By connecting the habit reversal training process to the person’s values and goals, they may be more motivated to change their behavior in order to live a life that is more in line with their values and purpose.
   4. Building self-efficacy: By providing the person with the skills, resources, and support they need to succeed, and by helping them see their own progress and accomplishments, they may feel more confident in their ability to make lasting changes to their behavior.

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:

1. 1. It helps to generalize the skills to other situations: By practicing the skills in a variety of different situations and contexts, the person is more likely to be able to use them effectively in the future, regardless of where they are or what they are doing.
   2. It helps to increase the person’s confidence and self-efficacy: By successfully using the skills and strategies in different situations, the person may feel more confident in their ability to apply them to new challenges and problems that may arise.
   3. It helps to promote long-term behavior change: By using the skills and strategies consistently over time, the person is more likely to make lasting changes to their behavior rather than just seeing temporary improvements.

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.

More: 

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)}}