Habit reversal training (HRT) is a behavioral therapy that teaches you to notice when an unwanted repetitive behavior is about to happen and replace it with a less harmful action. Developed in the early 1970s by psychologists Nathan Azrin and R. Gregory Nunn, it remains one of the most effective treatments for tic disorders, hair pulling, skin picking, and other body-focused repetitive behaviors. The approach is built on a simple insight: most habitual behaviors follow a predictable pattern, and if you can catch the pattern early enough, you can interrupt it.
The Three Core Components
HRT is structured around three interlocking skills that build on each other. Each one addresses a different part of the habit cycle.
Awareness Training
The first step is learning to recognize your behavior as it’s happening, or ideally, just before it starts. Many repetitive behaviors operate on autopilot. Someone who pulls their hair may not realize their hand has moved to their head until several strands are already gone. Awareness training breaks that autopilot by teaching you to identify the specific sensations, situations, and body positions that precede the behavior.
For tic disorders, this often means learning to detect a “premonitory urge,” a physical sensation like tingling, pressure, or tension that builds right before the tic occurs. For nail biting or skin picking, it might mean noticing when your hand drifts toward your face while you’re reading or watching TV. A therapist will typically have you describe the behavior in detail, practice identifying it in real time during sessions, and log occurrences between sessions so you start to see the triggers and patterns clearly.
Competing Response Training
Once you can reliably detect the urge or the onset of the behavior, the next step is substituting a “competing response,” a physical action that makes it difficult or impossible to perform the habit. The competing response needs to meet a few criteria: it should use the same muscles or body parts as the unwanted behavior, it should be something you can hold for one to two minutes, and it should be subtle enough that other people won’t notice.
For hair pulling, a common competing response is clenching your fists or pressing your hands flat against your thighs. For a head-jerking tic, it might be gently tensing the neck muscles in a steady downward position. For nail biting, you might grip an object or fold your hands together. The idea isn’t to suppress the urge through willpower. It’s to give your body something physically incompatible to do until the urge passes, which typically takes only a minute or two.
Social Support
The third component involves enlisting someone close to you, a parent, partner, or friend, to help reinforce the new skills. This person’s role is to offer encouragement when they see you successfully using a competing response and to gently point out when the old behavior resurfaces without you noticing. For children being treated for tics or hair pulling, parents usually take on this role. The support person isn’t there to police the behavior but to provide a second set of eyes during the early stages when self-awareness is still developing.
What Conditions HRT Treats
HRT is best established as a treatment for a specific cluster of conditions that involve repetitive, semi-voluntary behaviors:
- Trichotillomania (hair pulling): This is where some of the strongest evidence for HRT exists. In controlled studies, 76% of people receiving HRT responded to treatment, compared to just 21% of those receiving standard care.
- Tic disorders, including Tourette syndrome: HRT is the core technique inside a broader treatment package called Comprehensive Behavioral Intervention for Tics (CBIT), which was formalized around 2003. CBIT is essentially HRT with added relaxation training and strategies for managing the situations that worsen tics. It is now considered a first-line treatment for tics alongside medication.
- Dermatillomania (skin picking): The same awareness-plus-competing-response framework applies to compulsive skin picking, where the behavior often happens during idle moments or periods of stress.
- Stereotypic movement disorder: Repetitive, seemingly purposeless movements sometimes seen in children can also respond to the HRT approach.
HRT has also been adapted for more everyday habits like nail biting, thumb sucking, and teeth grinding, though the research base for these is smaller than for the conditions listed above.
How Effective It Is
The numbers for HRT are striking, particularly for hair pulling. In early research by Azrin himself, hair-pulling behavior dropped by 99% within the first day after training and remained reduced by 91% four months later. More recent controlled trials have confirmed these results in larger groups. One study found that 100% of people who completed an HRT program for trichotillomania qualified as treatment responders. Even in intent-to-treat analyses, which include people who dropped out, response rates reached 71%.
When HRT is combined with medication, results can improve further. One trial found a 54.5% response rate when HRT and a common antidepressant were used together, compared to 15.4% for either treatment alone. In a case study of someone with both OCD and trichotillomania, HRT reduced hair-pulling symptoms by 74% and OCD symptoms by 59%.
For tic disorders, the evidence is similarly strong. Multiple randomized controlled trials have shown that CBIT (which centers on HRT) produces clinically meaningful reductions in tic severity, with effects that hold up over follow-up periods of several months.
What Treatment Looks Like
HRT is typically delivered by a psychologist or therapist trained in behavioral interventions. Treatment is relatively short compared to many forms of therapy. Most programs run between 8 and 12 sessions, though the exact number depends on the severity of the behavior and how quickly you develop the core skills. Sessions are usually weekly and last about an hour.
The first few sessions focus heavily on awareness training: mapping out when, where, and how the behavior happens. Your therapist will likely ask you to keep a log between sessions, tracking each occurrence along with what you were doing, how you were feeling, and any physical sensations you noticed beforehand. This data becomes the foundation for designing your competing responses.
By the middle sessions, you’ll be practicing competing responses in the therapy room, sometimes with the therapist deliberately creating scenarios that trigger the urge. The goal is to build the new response into a reflex so it kicks in automatically when the urge arises in daily life. Later sessions shift toward generalization, making sure the skills work across different settings like work, school, or home, and toward troubleshooting situations where the old behavior tends to creep back.
Between sessions, you’ll practice on your own. The social support component is especially important during this phase. Having someone at home who knows what you’re working on and can offer low-key reminders makes a meaningful difference in how well the skills stick.
Why It Works
HRT doesn’t ask you to simply stop a behavior through force of will. That approach fails for most people because the urge to perform the behavior feels overwhelming, especially under stress. Instead, HRT works by breaking the habit loop at two points. First, awareness training disrupts the automatic, unconscious quality of the behavior. Once you can see the urge coming, it loses some of its power. Second, the competing response gives the urge somewhere safe to go. Rather than fighting the impulse, you redirect the physical energy into an action that’s harmless and invisible to others.
Over time, this process changes the relationship between the urge and the behavior. The urge doesn’t necessarily disappear, particularly with tic disorders, where premonitory sensations are neurologically driven. But the automatic link between feeling the urge and performing the behavior weakens. Many people find that the urges themselves become less frequent and less intense as the habit loop is consistently interrupted.
How to Find HRT
Not every therapist is trained in HRT, so it’s worth asking specifically about experience with this technique. Psychologists who specialize in cognitive behavioral therapy for tic disorders or body-focused repetitive behaviors are the most likely to offer it. The TLC Foundation for Body-Focused Repetitive Behaviors and the Tourette Association of America both maintain directories of trained providers. Some therapists now offer HRT through telehealth, which has expanded access significantly since the technique translates well to video sessions. The skills are concrete and observable, making remote coaching practical for most people.