DESCRIPTION OF THE STRATEGY

Habit reversal was developed by Nathan Azrin and Gregory Nunn in 1973 as a treatment for
habit disorders (nervous habits and tics). Habit reversal is best characterized as a treatment
package because it consists of multiple treatment components used in combination, typically
in outpatient treatment settings, with adults or children with habit disorders. Habit reversal
was originally developed to treat nervous habits and tics and modified a year later to treat
stuttering.
Habit reversal has been shown to be effective in treating a wide variety of habit disorders.
What characterizes each of these habit disorders is their repetitive nature. Habit behaviors
occur repeatedly across situations and continue to occur in the absence of social
reinforcement. Nervous habits, also called bodyfocused repetitive behaviors by some authors,
consist of repetitive hand-to-head behaviors such as hair pulling or hair twirling, hand-tomouth behaviors such as nail biting or thumb/finger sucking, hand-to-body behaviors such as
skin picking or scratching, and oral behaviors such as mouth biting or teeth grinding. There
are two types of tics: motor tics and vocal tics. Motor tics consist of rapid, repetitive, jerking
movements of muscle groups (e.g., head jerking, facial grimacing, shoulder shrugging), and
vocal tics consist of repetitive sounds and/or words spoken with no communicative function
(e.g., throat clearing, grunting, swear words). Motor and vocal tics may be part of a
diagnosable disorder such as Tourette's disorder. Stuttering involves disruption in the fluency
or timing of speech such as word, syllable, or sound repetition, prolongation of word sounds,
or blocking when attempting to speak.
There are four major components of the habit reversal procedure: awareness training,
competing response training, habit control motivation, and generalization training.

Awareness Training
The goal of awareness training is to teach the child to become aware of each instance of the
habit behavior or the immediate antecedents to the habit behavior. To accomplish this goal, a
number of procedures are used.
First is response description, in which the child describes all of the behaviors involved in the
habit. For example, if a child engages in hair pulling, the child would describe all of the
movements involved in pulling a hair (e.g., raising the right hand to the scalp, feeling hairs
with the fingertips, isolating a hair with the thumb and index finger, pulling the hair, rolling
the hair between the thumb and index finger, and finally dropping the hair on the floor).
After describing the behavior, the child practices response detection. In this procedure, the
therapist helps the child identify each instance of the habit behavior as it occurs in the session.
For behaviors such as tics or stuttering that would naturally occur in session, the therapist
engages the child in conversation and instructs the child to indicate each time the behavior
occurs. For behaviors such as hair pulling, nail biting, or other nervous habits that typically
occur only when the child is alone, the therapist has the child simulate the behavior in session
and identify each occurrence of the behavior.
In the early warning procedure, the therapist works with the child to identify when the
behavior is about to occur. For tics, the child might identify a physical sensation that typically
precedes the occurrence of the tic. For nervous habits, the therapist might help the child

identify the initial movements involved in the behavior (e.g., beginning to raise a hand to
engage in hair pulling). For stuttering, the therapist may help the child identify the initial
sound of a stutter to immediately recognize its occurrence.
In competing response practice, the child identifies a behavior that is incompatible with the
habit behavior and engages in this behavior for a few minutes to heighten his or her awareness
of the muscles involved in the habit behavior. For a motor tic, the competing response would
involve tightening the muscles involved in the tic and holding the body part immobile. For a
nervous habit involving the hands, the child might practice making a fist or grasping an
object. For stuttering, the competing response is diaphragmatic breathing with a slight exhale
before speaking.
The final awareness training procedure is situation awareness training, in which the therapist
helps the child identify each of the situations in which the habit behavior is most likely to
occur. For example, tics may be most likely to occur in stressful situations, nervous habits
may be most probable when the child is alone at certain times, and stuttering may be most
likely to occur with specific words or in specific evaluative situations.

Competing Response Practice

The next habit reversal procedure is competing response practice. As part of awareness
training, the child identifies one or more competing responses that are physically incompatible
with the habit behavior. In addition to being physically incompatible with the habit behavior,
the competing response is a socially inconspicuous behavior that the child can engage in
wherever and whenever the habit behavior occurs. The therapist instructs the child to engage
in the competing response for 1 to 3 minutes contingent on the occurrence of the habit
behavior or the antecedents to the habit behavior. If the child uses the competing response as
instructed, the competing response will interrupt the incipient occurrence of the habit or
prevent the occurrence of the habit.
The child practices the competing response in the treatment session with the guidance of the
therapist.
Each time the habit behavior occurs in session and the child uses the competing response, the
therapist provides praise. If the habit behavior occurs and the child fails to use the competing
response, the therapist prompts the child to engage in the competing response. The child
practices until he or she can successfully engage in the competing response to control the
habit behavior without any further prompting from the therapist. For habits that typically
occur only when the child is alone, the therapist instructs the child to simulate the habit
behavior in session and to use the competing response contingent on its occurrence. The child
practices using the competing response as he or she simulates the habit behavior in a variety
of situations (e.g., pulling hair while sitting at the desk at school).
Once the child has demonstrated mastery of the competing response in the treatment session,
the therapist instructs the child to use the competing response for 1 to 3 minutes contingent on
the habit behavior or antecedents to the habit behavior outside the treatment session. To help
motivate the child to use the competing response consistently outside the treatment sessions,
the therapist utilizes habit control motivation procedures.

Habit Control Motivation

Three procedures are used to help increase the child's motivation to use the competing
response to eliminate the habit behavior: habit inconvenience review, social support, and
public display procedures. In habit inconvenience review, the therapist asks the child (and
parent) to describe all the ways in which the habit behavior has caused inconvenience,
embarrassment, or disruption in the child's life. After reviewing the negative aspects of the
habit behavior, the child should be more motivated to carry out treatment procedures to
change the behavior. In the social support procedure, the therapist enlists the help of a
significant other (usually a parent) who helps the child control the habit behavior. Specifically,
the social support person is instructed to (a) praise the child for using the competing response
appropriately, (b) praise the child for the absence of the habit behavior in situations where the
habit typically occurred before treatment, and (c) prompt the child to use the competing
response if the child fails to use the competing response contingent on an instance of the habit
behavior. Finally, in the public display procedure, the therapist instructs the child to
demonstrate control of the habit behavior in session and in the presence of significant others
in order to receive social reinforcement for controlling the habit.

Generalization Training
The final component of habit reversal, generalization training, is intended to promote the use
of the competing response in all relevant situations outside the therapy sessions. To promote
the successful use of the competing response, the therapist has the child practice it in session
while providing social support. In addition, the child engages in symbolic rehearsal and
imagines using the competing response successfully and controlling the habit behavior in
everyday situations outside the therapy session.

RESEARCH BASIS
A large body of research has established the efficacy of habit reversal for eliminating or
substantially decreasing a wide range of habit behaviors. In this research, habit reversal is
implemented in one or a small number of outpatient sessions, and the habit behaviors are
measured for weeks or months following treatment. In some studies, booster sessions are
provided following the initial treatment sessions to maintain treatment gains.
Early research demonstrated the effectiveness of habit reversal for the treatment of nervous
habits and tics and for the treatment of stuttering. Subsequently, researchers have evaluated
habit reversal and variations of habit reversal using more rigorous research methods and have
found similar results. Research has demonstrated the effectiveness of habit reversal for
nervous habits, tics, and stuttering using single-subject designs and group designs. In addition,
researchers have shown that habit reversal is superior to alternative treatments such as massed
practice and to a placebo control group in the treatment of habit behaviors.
In addition to the basic demonstration of habit reversal as an effective procedure for a wide
range of habit behaviors, researchers have also demonstrated the effectiveness of simplified
versions for the procedure. Researchers have shown that the use of awareness training,
competing response training, and social support is effective for the treatment of nervous
habits, tics, and stuttering. Furthermore, researchers have demonstrated the effectiveness of
awareness training and competing response training alone, and some researchers have posited
that these are the two essential ingredients of the habit reversal procedure.

RELEVANT TARGET POPULATIONS AND

EXCEPTIONS
Habit reversal is an effective treatment for habit behaviors exhibited by adults, adolescents,
and children. Habit reversal procedures have not been found to be successful with individuals
with mental retardation or with very young children. A critical ingredient for success of habit
reversal is the ability of the child to understand the treatment instructions, demonstrate the
correct use of the procedures in session, and comply with the treatment procedures outside of
therapy sessions in everyday environments where the habit behaviors are likely to occur.
Therefore, habit reversal is most likely to be effective for those individuals who have the
cognitive capacity to understand and comply with the procedures and who are motivated to
change their behavior. Individuals with mental retardation or young children may lack the
skills or motivation to use the procedure successfully.

COMPLICATIONS
The effectiveness of habit reversal is likely to be compromised when the individual receiving
treatment does not want to change his or her behavior (e.g., a child or adolescent being
required to attend treatment by a parent). As stated, habit reversal is also least likely to be
effective with young children or individuals with intellectual disabilities. However, adjunct
treatments may enhance the effectiveness of habit reversal in such cases. For example, a
parent may provide tangible reinforcers for appropriate use of the competing response, may
implement response cost when the child does not use the competing response as instructed, or
may use physical guidance to ensure that the child uses the competing response at the
appropriate times. Finally, habit reversal may be less effective or ineffective with some severe
habit disorders in adolescents (e.g., hair pulling that meets the diagnostic criteria for
trichotillomania), especially if there is a comorbid disorder such as depression. In such cases,
other cognitive-behavioral interventions may be added to habit reversal to enhance its
effectiveness.

CASE ILLUSTRATION
Jennifer was a 12-year-old in sixth grade. She engaged in hair pulling in which she reached
up to her scalp just above her ear with her right hand, rubbed her fingertips in her hair, found
an individual hair that felt different, and pulled out the hair with her thumb and index
finger. After rubbing it between her thumb and finger for a few seconds, she dropped the hair
and repeated the behavioral chain. Jennifer pulled her hair almost exclusively while sitting on
her sofa alone watching television in the evening or on the weekends. She reported that she
did not engage in hair pulling at school, in any other public place, or in the presence of her
parents, although they sometimes walked in the room as she was engaging in hair pulling. She
occasionally pulled her hair in the car if she was in the back seat and her parents were not
watching. Jennifer had a 1-inch-diameter spot of thinned hair on her scalp, and she and her
mother spent time fixing her hair each morning so that the spot was not obvious to others. She
had been pulling her hair for a few years, although she could not identify a specific onset.
She sought treatment because she thought it was not normal and wanted her hair to grow
back before her classmates noticed.

Assessment information was collected from a behavioral interview with Jennifer and her
mother and through self-monitoring. Jennifer estimated that she pulled 10 to 20 hairs each day
before treatment. She did not report any negative emotion as an antecedent to hair pulling, and
simply said that it was a habit that she often did it without thinking about it. She usually sat
with her elbow on the arm of the sofa and her head resting on her hand. In this position, it
took little effort to pull her hair. For self-monitoring, Jennifer recorded on a small tablet how
many hairs she pulled each day. She kept the tablet on the table next to the sofa. In addition,
once per day she and her mother looked in a mirror at the spot of thinned hair on her scalp and
provided a numerical rating of the thickness of the hair. Using a 5-point rating scale, a rating
of 1 meant that there was no hair in the area, 2 was little hair, 3 was a medium amount of hair,
4 was hair mostly grown back, and 5 meant that the hair was fully grown in the area. Just
before treatment was implemented, Jennifer gave herself a rating of 2.5.
Habit reversal was implemented in one treatment session. Following the initial treatment
session, Jennifer was scheduled to attend two more sessions where she and the therapist
would review the treatment procedures and evaluate progress. One month later, a follow-up
session was planned.
In the treatment session, Jennifer described and demonstrated the hair pulling movements
without actually pulling a hair. Jennifer was instructed to simulate the hair pulling movements
10 times while sitting in the same position as she typically sat while pulling her hair at home.
In the simulations of the hair pulling, the therapist instructed Jennifer to stop at various points
in the movement to observe different stages of the behavior to heighten her awareness.
Following awareness training, the therapist introduced the rationale for the competing
response and Jennifer chose a number of competing responses that she could use while sitting
on the sofa watching television. The competing responses included holding a Koosh Ball,
holding on to the remote control, and sitting with her hands folded in her lap. Jennifer chose
the Koosh Ball as her primary competing response and always had it available on the sofa
when she sat down to watch television. In the session, Jennifer simulated the hair pulling
movements and engaged in the competing response before she pulled a hair. In each
simulation, she stopped herself at a different point in the movement (e.g., as she raised her
hand from her lap, when her hand touched her scalp) and engaged in the competing response.
In addition to instructions to use the competing responses, the therapist instructed Jennifer to
sit in a different position on the sofa so that her hand was not resting on her head. Even
though Jennifer did not pull her hair in the presence of her parents, the therapist enlisted her
mother to serve as a social support person. The therapist instructed her mother to check on
Jennifer at periodic intervals (every 1015 minutes) while Jennifer watched television and to
praise her when her hand was not touching her hair and when she was using the competing
response. Her mother was also instructed to prompt Jennifer to use the competing response if
she caught Jennifer with her fingers in her hair and not using the competing response. Her
mother readily agreed to carry out the procedures.
In the second treatment session 1 week later, Jennifer reported that she had pulled only one
hair on two different days and that, in response, she engaged in her competing response. On
all other days, she occupied her hands with the cushball while watching television and
prevented the hair pulling from occurring. On each occasion when she pulled her hair,Jennifer
was able to stop immediately and prevent further occurrences with the use of the competing
response. Her mother reported that she had not caught Jennifer with her fingers in her hair any
of the times she checked on her. After reviewing her self-monitoring data in this session,
Jennifer simulated hair pulling and practiced her competing responses a few times. She

brought her Koosh Ball to the session so she could practice holding the Koosh Ball as the
competing response. The session was brief because Jennifer was using the competing
response successfully and did not need further intervention.
Jennifer's mother called prior to her third scheduled appointment and cancelled the
appointment, saying that Jennifer did not need to come in for the session. She reported on the
phone that Jennifer had not pulled her hair in the preceding week and that she was
successfully using her competing response. She was extremely pleased with Jennifer's
progress (as was Jennifer) and scheduled an appointment 1 month later for a follow-up visit.
She also called to cancel her 1-month follow-up visit. She reported that Jennifer was no
longer pulling her hair, that she was using the competing response consistently, and that her
hair was growing back. Jennifer and her mom rated Jennifer's hair growth with a 4 (hair
mostly grown back) and were both confident that it was just a matter of time before their
ratings would be a 5 (hair fully grown back). She declined an offer for another follow-up
appointment.
Raymond G. Miltenberger
Further Reading

Entry Citation:
Miltenberger, Raymond G. "Habit Reversal." Encyclopedia of Behavior Modification and
Cognitive Behavior Therapy. 2007. SAGE Publications. 15 Apr. 2008. <http://sageereference.com/cbt/Article_n2065.html>.