Habit reversal training

1. Introduction

Version followed: the original Azrin & Nunn (1973) habit-reversal package as the reference structure; the three-component "simplified HRT" (awareness training, competing response, social support; Miltenberger and colleagues, 1990s) as the core you actually run; CBIT (Woods, Piacentini et al., 2008, Managing Tourette Syndrome therapist guide) for tics; and the TLC Foundation expert-consensus guidelines (2016) plus ACT-enhanced behaviour therapy (Woods & Twohig, 2008; 2nd edn 2023) for hair pulling, skin picking and other body-focused repetitive behaviours (BFRBs). Where these differ, the version is named in the text.

Habit reversal training (HRT) is a brief behavioural treatment for repetitive behaviours that run largely outside awareness: tics, hair pulling, skin picking, nail biting, cheek and lip biting, thumb sucking and (in the 1974 adaptation) stuttering. Azrin and Nunn first delivered it in a single counselling session of about two hours. [source: Allen & Kupfer, ABA blog; Sytsma-Jordan 2005]

Core idea of change: the habit persists because it is automatic, chained to cues the person does not notice, and reinforced (by urge relief, sensory reward or social consequences). Change comes from (a) making each occurrence and its earliest warning signs noticeable, (b) practising a physically incompatible response at that moment so the chain is interrupted and the urge is allowed to pass without being relieved, (c) arranging motivation and social reinforcement so the new response is maintained, and (d) rehearsing it across the situations where the habit occurs. CBIT adds that tics are made worse by situations and by how others react, so those contingencies are changed too. [source: Donohue & Farley 2005; Wilcox CBIT slides parts 1–2] Behavioural theory of urge reduction (CR should let the urge dissipate rather than relieve it) is from CBIT training material. [source: Wilcox, CBIT part 2]

2. Framework

HRT is a set of procedures rather than a fixed-length therapy. The original package had 9 to 13 procedures grouped into four components. [source: Sytsma-Jordan 2005] Below are the three main delivered formats.

2a. Original Azrin & Nunn (1973) package

Format: one session lasting one day (reported as about two hours), followed by telephone contacts; 12 volunteers aged 5 to 64. [source: Allen & Kupfer; Sytsma-Jordan 2005] Exact follow-up schedule [uncertain: original paper].
Components in order: (1) Awareness training: response description, response detection, early warning, situation awareness. (2) Competing response training: an incompatible, isometric response held for about three minutes on the urge or habit. (3) Motivation ("habit control motivation"): habit inconvenience (annoyance) review, social support, public display. (4) Generalization: symbolic rehearsal. Relaxation training is also part of the original list. [source: Donohue & Farley 2005; Allen & Kupfer; Sytsma-Jordan 2005] Additional named procedures commonly listed from the 1973 paper (habit interruption, positive practice, self-recording, posture adjustment) are [uncertain: from secondary sources].

2b. Simplified HRT (children and brief adult formats)

Components: awareness training, competing response, social support. [source: Sytsma-Jordan 2005; Miltenberger, Fuqua & Woods 1998]
Session count: one main session plus two to four shorter booster sessions for young children; Tourette's often needs many more sessions. [source: Sytsma-Jordan 2005]

2c. CBIT (tics; ages about 9 and over)

Format: 8 sessions; weekly for sessions 1–6, two weeks between sessions 7 and 8; booster sessions planned at the end. [source: Wilcox, CBIT part 2] In the original CBIT trials, sessions 1–2 were about 90 minutes and later sessions about 60 minutes, with monthly boosters after acute treatment [uncertain: from recall of the 2010 JAMA trial].
Session map [source: Wilcox, CBIT part 2]:
- Session 1: rapport, history, rationale, psychoeducation, tic hierarchy, function-based assessment, reward programme, start tic monitoring.
- Session 2: inconvenience review, hierarchy review, function-based assessment and HRT for tic 1, homework.
- Session 3: homework and hierarchy review, review HRT for tic 1, function-based assessment and HRT for tic 2.
- Sessions 4–6: same structure, one new tic per session, plus diaphragmatic breathing (4), progressive muscle relaxation (5), relaxation review (6).
- Sessions 7–8: same structure plus relapse prevention.

2d. ACT-enhanced behaviour therapy for trichotillomania (AEBT)

Format: 10 sessions over about 12 weeks (trial version). [source: Woods et al. 2022, contextualscience.org]
Session outline as presented in a training deck based on the Woods & Twohig manual: 1 introduction, trigger review, homework, expectations; 2 stimulus control and HRT; 3 values; 4–5 barriers to treatment, then acceptance and mindfulness; 6–7 cognitive defusion; 8 practice plus urge surfing; 9 practice and review; 10 review and relapse prevention. [source: Urbaniak 2023 slides] [uncertain: secondary summary, manual]

2e. Criteria for moving on (all versions)

From response description to detection: the client can describe the full movement sequence from first sensation to end without prompting. [source: Wilcox, CBIT part 2]
From detection to early warning, and from early warning to competing response: about 4 of 5 occurrences correctly signalled during in-session conversation. [source: Wilcox, CBIT part 2]
From CR practice to the next target behaviour (CBIT): CR performed correctly about 4 of 5 times in session, homework done, distress rating for that tic falling. Targets are added roughly one per session. [source: Wilcox, CBIT part 2]
Social support starts after the client shows control in session. [source: Donohue & Farley 2005]
Ending: hierarchy or self-monitoring shows sustained reduction; relapse plan written; booster dates set. [source: Wilcox, CBIT part 2; TLC 2016]

3. Guiding principles

Awareness first. You cannot interrupt what you do not notice; spend real session time on detection before any competing response. [source: Wilcox, CBIT part 2]
Intervene at the very start of the chain. Aim the CR at the premonitory urge or the first movement, not the completed habit. [source: Wilcox, CBIT part 2; Allen & Kupfer]
The CR lets the urge pass; it does not relieve it. Hold until the urge fades, not until the person feels "just right". [source: Wilcox, CBIT part 2]
Physically incompatible, less noticeable, usable anywhere. These three tests decide every CR. [source: Wilcox, CBIT parts 1–2]
The client chooses the CR. You may offer options, but use only one the client accepts. [source: Wilcox, CBIT part 2]
Practise to criterion in session. Rehearse with feedback during ordinary talk until about 4 of 5 are correct; do not rely on explanation. [source: Wilcox, CBIT part 2]
Reward effort, not success. Points and praise go to practice, attendance and homework, not to tic-free periods. [source: Wilcox, CBIT part 1; TLC 2016]
Supporters encourage, never punish. One gentle reminder per setting; praise practice. It is the client's treatment. [source: Wilcox, CBIT part 1]
Function matters. Look for situations and reactions that make the behaviour more likely and change them. [source: Wilcox, CBIT part 1; TLC 2016 ComB]
Tools, not a cure. Set realistic expectations; slips are expected and are problems to solve, not failures. [source: Wilcox, CBIT part 1; TLC 2016]
Work one target at a time. Start with the most bothersome behaviour, balanced against the client's preference and likelihood of success. [source: Wilcox, CBIT part 2]
Treat the person, not only the behaviour. Balance habit work with shame, mood and life issues; focusing only on either one raises relapse risk. [source: TLC 2016]
Willingness over suppression (AEBT version). Urges are to be noticed and allowed while the person acts on values, not fought or eliminated. [source: TLC 2016 on Woods et al.]

4. Intervention inventory

Order: preparation and motivation (4.1–4.4), awareness training (4.5–4.9), competing response and related original procedures (4.10–4.15), motivation and generalisation (4.16–4.19), function and environment (4.20–4.22), acceptance-based additions (4.23–4.27), offshoot techniques (4.28–4.29), ending (4.30). Example language is my own illustrative wording throughout.

4.1 Psychoeducation and rationale

Purpose / when: Session 1 of every format. Reduces shame and blame, explains why awareness and a competing response work, and sets expectations.
Steps: (1) Explain the diagnosis in plain terms (for tics: Tourette's, persistent motor or vocal tic disorder, provisional tic disorder; for BFRBs: hair pulling, skin picking and related behaviours). (2) Describe premonitory urges (an itch or pressure, like needing to sneeze), noting that not everyone has them, especially younger children. (3) Cover typical course: tics often start around 6–9, peak around 8–12 and often lessen in adulthood. (4) Explain the model: behaviour is automatic, cue-linked and reinforced by relief; therapy builds awareness and an incompatible response. (5) State plainly that this is a set of tools, not a cure, and that practice between sessions is what makes it work. (6) For children, involve parents for part of each session. [source: Wilcox, CBIT parts 1–2; TLC 2016]
Example language (illustrative): "The urge is a bit like an itch. Each time the tic scratches it, your brain learns that the tic is the way to get relief. We're going to teach it a different ending: the urge rises, you hold a small counter-movement, and the urge fades by itself."
Watch for: Parents who believe the child can simply stop; clients who hear "not a cure" as "won't help". It is working when the client can explain the urge-relief loop in their own words.

4.2 Baseline assessment and self-monitoring

Purpose / when: Before and throughout treatment, to find patterns and measure change. CBIT calls it necessary but not sufficient. [source: Wilcox, CBIT part 1]
Steps: (1) List all target behaviours (CBIT uses a tic inventory such as the YGTSS checklist; do not reproduce instrument items). (2) Set recording periods: in CBIT about 30 minutes, 3–4 times a week, at high-frequency times; tally each occurrence. (3) For BFRBs, record each episode with situation, time, emotion, what was done with the hair or skin, and duration (ComB-style monitoring). (4) Where possible, have a parent or support person also record. (5) Once the CR starts, also record how often it was used and how well it worked. [source: Wilcox, CBIT part 2; TLC 2016] Exact BFRB record fields are my [synthesis].
Example language (illustrative): "For the next week I'd like you to pick a half-hour after school when the tics are busiest and make a tick mark each time. We're not trying to change anything yet, only to see the pattern."
Watch for: Warn that monitoring can make the behaviour seem worse at first because attention is on it. [source: Wilcox, CBIT parts 1–2] Working when records come back complete enough to show times, places and triggers.

4.3 Habit inconvenience (annoyance) review

Purpose / when: Original motivation procedure and CBIT session 2. Builds motivation for effortful practice. [source: Donohue & Farley 2005; Wilcox, CBIT part 2]
Steps: (1) Ask the client to list every problem the behaviour causes: physical (pain, bald patches, damaged skin, scarring), social (teasing, avoidance), emotional (embarrassment, shame), practical (time lost, hiding it). (2) Prompt for areas they have missed. (3) Discuss what would be better without it. (4) Write the list down and return to it when motivation drops. [source: Donohue & Farley 2005; Wilcox, CBIT part 1]
Example language (illustrative): "Let's write down everything the picking costs you, big and small. Then let's write what you'd do or feel differently if it took up much less of your life."
Watch for: Shame spirals; keep the tone factual, not blaming. Working when the client links practice to items on their own list.

4.4 Tic (or habit) hierarchy

Purpose / when: CBIT session 1, reviewed every session. Picks the order of targets and tracks progress. [source: Wilcox, CBIT parts 1–2]
Steps: (1) List every current tic. (2) Have the client rate each for distress on a 0–10 scale. (3) Pick the first target: usually the most bothersome, adjusted for client preference and likelihood of success. (4) Re-rate every session; add new tics as they appear. (5) Use the ratings as a progress graph to show change that the client may not feel. [source: Wilcox, CBIT part 2] Applying the same hierarchy to multiple BFRB sites is my [synthesis].
Example language (illustrative): "Of all these tics, which one bothers you most right now? Let's rate each from 0 to 10 and start with one that's bothersome but that you think we could get a handle on."
Watch for: Starting with a very complex or very frequent tic that sets the client up to fail. Working when ratings for treated tics fall across sessions.

4.5 Response description

Purpose / when: First awareness step for each new target. [source: Donohue & Farley 2005; Wilcox, CBIT part 2]
Steps: (1) Explain why awareness comes first. (2) Ask the client to describe the behaviour in detail from the first sensation to the end: body parts involved, order of movements, sensations. Original procedure used a mirror while re-enacting it. (3) Start at the focal point and work outward to subtle accompanying movements. (4) For vocal tics, ask also about the movement, not only the sound. (5) If the client cannot produce it in session, ask them to imitate it. (6) Let the client work first; only offer what you observed when they run out. (7) Write a short agreed definition. [source: Donohue & Farley 2005; Wilcox, CBIT part 2]
Example language (illustrative): "Walk me through it in slow motion. Where do you feel it first? What moves first, then what? What does your shoulder do? Your eyes?"
Watch for: Therapist errors: jumping in too early, stopping too early, accepting a cursory description. Practising the tic yourself beforehand helps you prompt. [source: Wilcox, CBIT part 2] Working when the description is precise enough that you could recognise the behaviour from it.

4.6 Response detection

Purpose / when: Right after description. Teaches the client to notice every occurrence. [source: Wilcox, CBIT parts 1–2; Donohue & Farley 2005]
Steps: (1) Demonstrate: you do the behaviour and the client signals. (2) Agree a signal (CBIT: raise a forefinger). (3) Talk about something ordinary while the client signals each occurrence; simulate if it is not happening naturally. (4) Praise each correct signal; point out any missed one immediately. (5) Continue until about 4 of 5 occurrences are caught. [source: Wilcox, CBIT part 2]
Example language (illustrative): "Let's chat about your week. Whenever the tic happens, just lift a finger. I'll let you know if I see one you missed." ... "Nice catch." ... "That one just now, did you feel it?"
Watch for: Therapist staring (makes the setting unnatural) or getting so absorbed in conversation that feedback is missed; this is harder for talk therapists. [source: Wilcox, CBIT part 2] Working when the client reaches criterion and starts reporting noticing at home.

4.7 Early-warning (premonitory urge) detection

Purpose / when: After response detection. Moves the point of intervention to before the behaviour. [source: Donohue & Farley 2005; Wilcox, CBIT part 2]
Steps: (1) Ask the client to describe the signals that precede the behaviour: urge, sensation, location; for BFRBs also early motor steps such as a hand moving towards the face or touching the hair. (2) Repeat the detection drill, now signalling the urge before the behaviour. (3) Feedback and praise until about 4 of 5. [source: Wilcox, CBIT part 2] Using early motor steps as the warning signal for BFRBs is consistent with TLC/DBT descriptions; the drill wording is my [synthesis].
Example language (illustrative): "This time, see if you can lift your finger when you first feel the urge, before the tic happens."
Watch for: Focusing on the urge can make it feel stronger at first; normalise this. [source: Wilcox, CBIT part 2] Some tics and many automatic BFRBs have no clear urge; then use the first movement as the cue. [source: Wilcox, CBIT part 2]

4.8 Situation awareness training

Purpose / when: Original awareness component; also core of BFRB awareness training. [source: Donohue & Farley 2005; TLC 2016]
Steps: (1) From monitoring and interview, list the situations, people, places, times, activities and emotional states in which the behaviour is most likely (for BFRBs: lying in bed, driving, at the computer, in front of a mirror). (2) Describe how the behaviour looks in each. (3) Mark these as practice and high-risk situations for the CR and for stimulus control. [source: Donohue & Farley 2005; TLC 2016]
Example language (illustrative): "From your records, most picking happens in the bathroom at night and while you study. Those two places are where we'll focus the plan."
Watch for: Over-long lists; prioritise the two or three highest-risk settings.

4.9 Awareness aids (barriers)

Purpose / when: BFRBs, when episodes happen out of awareness. [source: TLC 2016]
Steps: Agree a physical cue that makes the behaviour harder or noticeable: gloves, plasters or medical tape on fingertips, a hat, a bracelet. Use in high-risk situations identified in 4.8. [source: TLC 2016]
Example language (illustrative): "What if you wore tape on the two fingers you use most while you're reading? It won't stop you, but it'll make you notice."
Watch for: Barriers removed without noticing; pair them with the CR so noticing leads to action.

4.10 Competing response selection

Purpose / when: After awareness reaches criterion for a target. Picks the counter-behaviour. [source: Wilcox, CBIT part 2; Donohue & Farley 2005]
Steps: (1) Explain the tests (CBIT version): the behaviour cannot be done during the CR, and the CR makes any partial behaviour less visible; it can be held at least one minute or until the urge passes, anywhere; it is less noticeable than the behaviour. (2) Original version adds: opposite in direction to the habit movement, isometric tension of the involved muscles, compatible with normal activities. Newer applications are less strict, especially with young children. (3) Ask the client to propose a CR; test it against the rules; repeat until one fits. (4) If stuck, offer options, but use only one the client accepts. (5) Target the very beginning of the movement. [source: Wilcox, CBIT part 2; Donohue & Farley 2005; Sytsma-Jordan 2005]
Examples of CRs from sources: pushing feet into the floor or locking knees (leg tics); slight jaw clench with lips pressed together (mouth or facial tics); locking elbows with fingers extended (arm and hand tics); tucking the chin and tensing neck muscles (head jerks); clenching fists, folding hands, sitting on hands, hands in pockets, crossing arms (hair pulling, picking, nail biting); slow regulated breathing (vocal tics, stuttering). [source: Wilcox, CBIT part 2; TLC 2016; Sytsma-Jordan 2005; Moritz et al. 2022]
Example language (illustrative): "What could you do with your neck that makes it impossible to jerk your head, that you could keep up for a minute in class, and that nobody would notice?"
Watch for: Therapist imposing the CR; a CR that is more conspicuous than the tic; a CR that does not block the first part of the movement. [source: Wilcox, CBIT part 2]

4.11 Competing response practice (in session)

Purpose / when: Immediately after selection. Builds the urge-to-CR link. [source: Wilcox, CBIT part 2]
Steps: (1) Model the CR, including how long one minute feels. (2) Client rehearses it once with feedback on form. (3) Run a conversation or game; client does the CR as soon as they notice the urge or the start of the behaviour, holds it at least one minute or until the urge passes (CBIT training material also states "whichever is longer"), and keeps talking. (4) Give feedback on each trial: timing, form, duration. (5) Continue until about 4 of 5 trials are correct. Original 1973 practice held the CR about three minutes; later protocols use 1–3 minutes. [source: Wilcox, CBIT part 2; Allen & Kupfer; Sytsma-Jordan 2005] [uncertain: CBIT material is internally inconsistent on "until urge passes" versus "whichever is longer"; I follow "whichever is longer"]
Example language (illustrative): "Keep telling me about the match. When the urge comes, press your feet down and keep going... that's thirty seconds, keep holding... and that's a minute. Is the urge still there?"
Watch for: Releasing the CR at the peak of the urge; no feedback during practice; too short a hold. Working when the client starts the CR at the urge, not after the tic, and reports the urge subsiding.

4.12 Competing response homework (planned and unplanned)

Purpose / when: Every session from the first CR onwards. [source: Wilcox, CBIT part 2]
Steps: (1) Planned practice: set specific times (ideally high-risk ones) to practise the CR deliberately. (2) Unplanned use: every time the urge or behaviour is noticed in daily life. (3) Keep using CRs for all previously treated tics as well as the current one. (4) Record use and effect (4.2). [source: Wilcox, CBIT part 2]
Example language (illustrative): "Twice a day during homework time you'll practise on purpose. And any other time you catch the urge, use it. Jot down roughly how many times and whether it helped."
Watch for: Stopping CRs for earlier targets once a new one starts.

4.13 Habit interruption, positive practice and posture adjustment (original package)

Purpose / when: Original 1973 procedures sometimes listed beside the CR: interrupting the habit as soon as it starts, extra deliberate practice of the CR, and adjusting posture. [uncertain: names from secondary recall; the 1973 paper is not drawn on and no source describes their steps.] Current protocols fold their function into CR practice (4.11–4.12); Separate steps are not given, to avoid inventing them.

4.14 Relaxation training

Purpose / when: Original package and CBIT sessions 4–6. Reduces general arousal and anxiety that make tics worse; in CBIT it is not itself a CR. [source: Wilcox, CBIT parts 1–2]
Steps: (1) Diaphragmatic breathing: hand on belly, slow breaths from the diaphragm; for children use games such as blowing out candles, blowing up a balloon, or four-square (box) breathing. (2) Progressive muscle relaxation: tense a muscle group 5–10 seconds, release and notice relaxation for 5–10 seconds, working through the body; use an age-appropriate script for young children. (3) Assign daily practice and use in tic-provoking or stressful situations. [source: Wilcox, CBIT part 2]
Example language (illustrative): "Breathe in slowly so your hand on your tummy rises, then out through your mouth like you're blowing out a candle very gently."
Watch for: PMR tension that triggers tics in the same muscles; modify by skipping or softening that group [synthesis].

4.15 Regulated breathing (stuttering adaptation)

Purpose / when: Azrin & Nunn's 1974 adaptation of HRT for stuttering. [source: Allen & Kupfer]
Steps: Awareness of stuttering topography, words and situations that evoke it, and associated movements; competing responses of controlled breathing, pausing before speaking, and relaxation; family prompting and praising fluent speech; imagined rehearsal in evoking situations. [source: Allen & Kupfer] Breath-by-breath steps are not given in the sources [uncertain]; coordinate with a speech-language therapist [synthesis].
Example language (illustrative): "When you feel a block coming, stop, let a slow breath out, take an easy breath in, and start the word on the outgoing breath."
Watch for: Breathing used as a hurried trick; aim for a calm pause.

4.16 Social support procedure

Purpose / when: Original package and every simplified/CBIT version; essential for young children. Introduced after the client shows control in session. [source: Donohue & Farley 2005; Sytsma-Jordan 2005]
Steps: (1) Choose one support person (parent for a child; spouse, housemate or sibling for an adult). (2) Bring them to a session; explain the model and show them the CR. (3) Teach them to: praise the client for using the CR and for habit-free periods; give a gentle prompt to use the CR when they notice an occurrence the client missed (CBIT: at most one reminder per setting); for young children, physically guide the CR if needed. (4) Teach them never to criticise, punish, tell the person not to tic, or laugh. (5) Praise practice, not success. [source: Wilcox, CBIT part 1; Donohue & Farley 2005; Sytsma-Jordan 2005; TLC 2016]
Example language (illustrative, to the supporter): "If you see the tic and Sam doesn't use his exercise, you can say once, quietly, 'Remember your feet.' When you see him doing it, a simple 'Nice job practising' is perfect."
Watch for: Nagging, policing, or praise only for tic-free periods. Working when the client says reminders feel helpful, not intrusive.

4.17 Public display (display of improvement)

Purpose / when: Original motivation procedure, after some control is achieved. [source: Donohue & Farley 2005]
Steps: The client demonstrates control (and the CR) in front of a friendly audience such as family or friends, who acknowledge the progress. [source: Donohue & Farley 2005]
Example language (illustrative): "Would you be willing to show your mum what you've learned today, and how long you can go now?"
Watch for: Pressure or embarrassment; make it optional, especially for adolescents [synthesis].

4.18 Symbolic rehearsal (generalisation training)

Purpose / when: Original generalisation procedure; useful before testing the CR in high-risk settings. [source: Donohue & Farley 2005; Allen & Kupfer]
Steps: (1) Take a high-risk situation from 4.8. (2) Client imagines being there in detail, notices the early warning sign, and actually performs the CR while imagining. (3) Repeat across several situations. [source: Donohue & Farley 2005; Allen & Kupfer]
Example language (illustrative): "Close your eyes. You're in bed with your phone, your hand drifts up to your hair... the moment you feel it start, make your fists and hold them. Tell me what happens."
Watch for: Rehearsal of the habit instead of the CR; keep imagery short and end with the CR.

4.19 Reward (behavioural incentive) programme

Purpose / when: CBIT session 1 onward for children; useful for low motivation. [source: Wilcox, CBIT parts 1–2; TLC 2016]
Steps: (1) With parent and child, set points for attending, participating, completing homework and working hard in session. (2) Agree what points buy (often non-monetary: staying up later, choosing a family film). (3) Review weekly. (4) Reward use of strategies, never absence of tics or pulling. [source: Wilcox, CBIT part 1; TLC 2016]
Example language (illustrative): "Every time you do your practice and write it down, you get a point. Five points means you choose Friday's film."
Watch for: Parents linking rewards to tic-free days; correct immediately.

4.20 Function-based assessment and interventions (CBIT)

Purpose / when: Each session in CBIT, for each target tic. Finds and changes antecedents and consequences that make tics worse. [source: Wilcox, CBIT parts 1–2]
Steps: (1) Interview parent and child (or adult) using an antecedent–behaviour–consequence frame: which people, places, activities, demands and feelings make tics worse; what happens after (comfort, teasing, being sent out, getting out of tasks, getting attention). (2) Antecedent changes: bedtime routines with relaxation, scheduling car trips at lower-tic times, preferred seating, about 15 minutes of downtime before demands, limiting a triggering activity. (3) Consequence changes: others stop commenting, comforting or laughing during tics; peers encouraged not to react; the person is not removed from class or tasks; homework is still required; supporters may remind about the CR. (4) Write an implementation plan with parents and school: who does what and when; anticipate obstacles and train those involved. [source: Wilcox, CBIT part 1]
Example language (illustrative): "When the tics get loud at dinner, what usually happens next? ... So he gets sent to his room and misses the washing up. Let's try keeping everything the same, no comments, and he stays."
Watch for: Parents feeling blamed; frame it as tics being sensitive to setting, not caused by parenting. Working when the identified high-tic situations improve.

4.21 Stimulus control (BFRBs)

Purpose / when: BFRBs, alongside HRT; core part of AEBT session 2. Makes the behaviour harder to do or less cued, not to remove urges. [source: TLC 2016; Urbaniak 2023]
Steps: (1) From monitoring, list external triggers (places, activities, objects: mirrors, tweezers, bright bathroom light, bed, car) and internal triggers (sensations, thoughts, feelings). (2) For each high-risk setting, agree one or two changes: cover or remove magnifying mirrors, dim bathroom light, remove tweezers, limit time in the bathroom, keep hands busy while reading or driving, wear barriers (4.9). (3) Review weekly and keep only what is used. [source: TLC 2016] Bathroom time limits and "keep only what is used" are my [synthesis].
Example language (illustrative): "Your records say the magnifying mirror is where long sessions start. Would you be willing to put it away for the next two weeks and see what happens?"
Watch for: Stimulus control becoming avoidance that shrinks life; in AEBT its job is to make values-based activity easier. [source: TLC 2016]

4.22 ComB model: SCAMP assessment and individualised strategies

Purpose / when: BFRBs, when standard HRT is not enough or episodes serve several needs. The model (Mansueto and colleagues) assumes the behaviour meets a need such as soothing, falling asleep or a sense of accomplishment. Its stages: assessment, identify target modalities, choose strategies, evaluate. [source: TLC 2016] The TLC guidelines note it has limited empirical evaluation.
Steps: (1) Assess episodes by the five SCAMP domains: Sensory (what is sought or felt: itching, texture, smoothness, sight), Cognitive (thoughts and beliefs such as rules about coarse hairs), Affective (feelings before and after), Motor (hand positions, automatic movements), Place (settings, lighting, mirrors). (2) Mark the domains that drive this client's episodes. (3) Choose a strategy per active domain: a wide-tooth comb for scalp itch (also keeps fingertips off the scalp); a smooth stone to hold for the urge to feel smoothness; cognitive work on rigid beliefs or worry; competing responses or barriers for motor patterns; mirror and lighting changes for place. (4) Evaluate each strategy from monitoring and revise. [source: TLC 2016]
Example language (illustrative): "When you pull, is it more about the feel of the hair, a thought that it has to go, how you're feeling, where your hands are, or where you are? Usually it's a mix; let's find yours."
Watch for: A long menu of strategies none of which is practised; choose few and test them.

4.23 Values clarification (AEBT)

Purpose / when: AEBT session 3 and onward. Provides the reason to tolerate urges. [source: Urbaniak 2023; TLC 2016]
Steps: (1) Identify what matters to the client in key areas of life. (2) Examine whether pulling or the struggle against urges moves them towards or away from those values. (3) Link HRT and stimulus control to values-based goals. [source: TLC 2016]
Example language (illustrative): "If hair pulling weren't taking up so much room, what would you be doing more of? Which of those matters most?"
Watch for: Values stated as "stop pulling"; redirect to what they want to move towards.

4.24 Barriers, acceptance and willingness (AEBT)

Purpose / when: AEBT sessions 4–5. Targets the struggle with urges and emotions that keeps the cycle going. [source: Urbaniak 2023; TLC 2016]
Steps: (1) Identify internal barriers to treatment (urges, uncomfortable feelings, thoughts) and how the client has tried to control or avoid them. (2) Explore what those control efforts have cost. (3) Introduce acceptance: noticing urges and feelings without judging them, as temporary experiences that need not be acted on. (4) Ask for a commitment to tolerate discomfort rather than escape it. [source: TLC 2016] The specific ACT exercises used in the manual are not described here [uncertain].
Example language (illustrative): "What if the urge could just be there, like weather, while your hands stay in your lap and you keep reading?"
Watch for: Acceptance heard as resignation; stress acceptance of urges, not of pulling.

4.25 Mindfulness of triggers and early movements

Purpose / when: AEBT session 5 onward; also the DBT-enhanced version. [source: Urbaniak 2023; TLC 2016]
Steps: Practise present-moment noticing of triggers, sensations and the early motor movements before pulling, and of strong emotions without acting on them. Use brief daily exercises and in high-risk situations. [source: TLC 2016] Exercise format is my [synthesis].
Example language (illustrative): "For the next minute, just notice where your hands are and any sensation in your scalp, without doing anything about it."
Watch for: Mindfulness used to make urges go away; the aim is noticing.

4.26 Cognitive defusion (AEBT)

Purpose / when: AEBT sessions 6–7. Loosens the pull of urge-related thoughts ("I have to get this one"). [source: Urbaniak 2023]
Steps: Teach the client to notice thoughts as thoughts rather than commands, and practise responding to urge-thoughts without obeying or arguing with them. [source: Urbaniak 2023 (named only)] Specific exercises are not in the sources [uncertain]; standard ACT practice is to label the thought ("I'm having the thought that...") [synthesis].
Example language (illustrative): "Notice the thought 'this hair feels wrong'. Can you say, 'I'm having the thought that this hair feels wrong', and keep your fists closed?"
Watch for: Defusion used to argue the thought away.

4.27 Urge surfing (AEBT) and DBT-enhanced skills

Purpose / when: AEBT session 8 (urge surfing). DBT-enhanced behaviour therapy (Keuthen) adds emotion regulation and distress tolerance modules to HRT for hair pulling where emotional triggers dominate. [source: Urbaniak 2023; TLC 2016]
Steps: Urge surfing: notice the urge, observe its rise, peak and fall without acting, pairing it with the CR if needed. DBT additions: mindfulness of triggers and early movements; emotion regulation (identify and label emotions, reduce vulnerability, increase positive events, opposite action); distress tolerance (get through short crises and tolerate urges without acting). [source: TLC 2016] Urge-surfing steps are my [synthesis]; source names it only.
Example language (illustrative): "Rate the urge 0 to 10 now. Keep your hands where they are and rate it again every 30 seconds. Let's see what it does."
Watch for: Urge not peaking in session; extend the practice or combine with the CR.

4.28 Decoupling

Purpose / when: Self-help offshoot for BFRBs, especially nail biting and hair pulling (Moritz and colleagues). Unlike the static HRT CR, it uses a dynamic movement practised also when no urge is present. [source: Moritz et al. 2022; Moritz et al. 2023]
Steps: (1) Observe the behaviour first without interfering, to learn its typical motor pattern and triggers. (2) Start the usual approach movement (for example, hand towards mouth). (3) Just before reaching the target, redirect the hand with a quick, accelerated movement to another place on the body (such as the ear) or a point in the room. (4) Start with the earliest part of the sequence. (5) Practise in symptomatic and symptom-free periods, using a phone timer as a reminder. [source: Moritz et al. 2022; Moritz et al. 2023]
Example language (illustrative): "Bring your hand up towards your mouth as you would, and just before it gets there, flick it quickly to your earlobe. Again. Several times a day, even when you don't feel like biting."
Watch for: Practising only during urges; generalisation depends on routine practice.

4.29 Decoupling in sensu

Purpose / when: Variant of 4.28 using imagery, meant to help generalise across body sites. [source: Moritz et al. 2023]
Steps: (1) Close eyes and imagine the motor sequence that leads to the behaviour. (2) Just before the imagined behaviour would be completed, make a real movement: for nail biting, hand clenched in a fist during imagery is moved quickly downward away from the body with fingers spread wide. (3) Practise in symptom-free periods with timer reminders. [source: Moritz et al. 2022; Moritz et al. 2023]
Example language (illustrative): "Picture your hand rising to your mouth... now, for real, push your fist down and spread your fingers."
Watch for: Imagery that triggers the actual behaviour; shorten it.

4.30 Relapse prevention and booster sessions

Purpose / when: Final sessions of every format (CBIT 7–8; AEBT 10). [source: Wilcox, CBIT part 2; Urbaniak 2023; TLC 2016]
Steps: (1) Review what worked for each target. (2) Set realistic expectations: slips are expected; tics wax and wane; BFRB improvement is slow and steady, not a cure. (3) Plan for high-risk periods (exams, stress, illness, transitions) and new tics: apply awareness and CR to any new behaviour. (4) Write a lapse plan: accept the lapse non-judgementally, work out why it happened, return to techniques that worked. (5) Schedule boosters and say when to make contact again. (6) Refer for other needs. [source: Wilcox, CBIT part 2; TLC 2016]
Example language (illustrative): "A bad week isn't starting over. It's a sign to dust off the plan: what was going on, which strategy dropped, and what you'll restart tomorrow."
Watch for: Feeling "cured" and seeing a setback as failure, or waiting to see what happens without problem-solving; both predict relapse. [source: TLC 2016]

5. Handling problems

Low commitment or non-adherence to homework. CBIT material is blunt: if client and parent are not willing to do homework, CBIT will not help. [source: Wilcox, CBIT part 1] Responses: revisit the inconvenience review (4.3); set a reward programme for effort (4.19); for teens, allow time and privacy to become ready, and do not let parental motivation substitute for the young person's. [source: TLC 2016] Shrink homework to one planned practice a day and one recording period, tied to an existing routine; troubleshoot the specific obstacle each week [synthesis].

"It makes it worse" after awareness training. Monitoring and early-warning work raise attention to urges and can make tics or urges feel stronger at first. [source: Wilcox, CBIT parts 1–2] Respond by predicting this in advance, normalising it as temporary, and showing hierarchy ratings over time. The broader debate about increased tic awareness is noted in the codebook; No source quantifies it [uncertain].

No noticeable premonitory urge. Common in young children, people with cognitive delay, and automatic (unfocused) pulling or picking. [source: Wilcox, CBIT part 2] Use the first movement (hand moving to face, start of a tic) as the cue; add awareness aids such as barriers (4.9) and stimulus control (4.21); use decoupling (4.28), which is practised outside urge periods. Using decoupling for this purpose is my [synthesis].

CR not working (behaviour breaks through, urge stays). Check, in order: (1) Does the CR start at the very beginning of the movement? (2) Is it held long enough, at least a minute and past the urge? (3) Is it truly incompatible with the movement? (4) Was it practised to criterion in session? (5) Did the client choose it? These map onto the common mistakes listed in CBIT training. [source: Wilcox, CBIT part 2] If all are in place, redesign the CR with the client; for complex tics, target the first component only [synthesis].

CR too conspicuous or embarrassing. The rule is that the CR must be less noticeable than the behaviour. [source: Wilcox, CBIT part 2] Reduce its intensity (slight tension rather than visible bracing), or switch to an option usable in public (hands folded, feet pressed down) [synthesis].

New tics appear or tics shift. Add them to the hierarchy and treat in turn; the hierarchy is re-rated each session. [source: Wilcox, CBIT part 2] Explain that tics naturally wax, wane and change, so a new tic is not a side effect of therapy. Making this specific link to substitution concerns is my [synthesis].

Young children. Use simplified HRT with heavy social support, parent prompting and physical guidance of the CR, and less strict CR rules; expect one session plus two to four short boosters. [source: Sytsma-Jordan 2005] CBIT is intended for about age 9 and over. [source: Wilcox, CBIT part 1] Keep sessions short, use games for awareness drills and points for practice [synthesis].

ADHD and attention difficulties. Shorter, more frequent sessions, separate parent sessions, fewer distractions, extra reinforcers. [source: Wilcox, CBIT part 1]

Developmental disabilities. More direct, rule-specific instruction and more concrete reinforcers. [source: Wilcox, CBIT part 1]

Tics versus compulsions. Tics involve vague sensory discomfort without specific feared consequences; OCD compulsions are driven by beliefs that something bad will happen and need exposure and response prevention. [source: Wilcox, CBIT part 1] Ask what would happen if the person did not do it; a feared outcome points to OCD treatment.

Comorbid depression, anxiety, rage. CBIT training advises treating depression before CBIT and treating anxiety first if it is not secondary to tics; rage outbursts (reported in a sizable minority of children with Tourette's) get standard anger support. [source: Wilcox, CBIT part 1] For BFRBs, address shame, isolation and low self-esteem alongside the behaviour. [source: TLC 2016] Screen for suicidal thinking in depressed or highly ashamed clients using standard risk assessment and safety planning [synthesis].

Overwhelm during practice (urge spikes, distress). Lower the demand: shorter CR holds building up, practise in a low-trigger setting first, add diaphragmatic breathing (4.14) before the CR [synthesis]. For emotion-driven pulling, add DBT distress-tolerance and emotion-regulation skills (4.27). [source: TLC 2016]

Family conflict, nagging, punishment. Retrain the supporter: one reminder per setting, praise practice not success, no criticism or laughing. [source: Wilcox, CBIT part 1] If the family cannot do this, reduce the supporter's role to praise only and have the client self-prompt with a cue (watch vibration, sticker) [synthesis].

Ruptures (client feels blamed, controlled or disbelieved). Not addressed in the sources [uncertain]. My guidance [synthesis]: name it directly, return choice to the client (they choose CR, targets and supporter), check whether functional assessment sounded like blaming the family, and validate that the behaviour is neurobiologically driven and not a matter of willpower.

Lapses and relapse after treatment. Expect slips; analyse the slip, restart prior techniques, take a non-judgemental view of returning urges, and book a booster in high-risk periods; if old techniques stop working, try new interventions such as ComB or AEBT components. [source: TLC 2016; Wilcox, CBIT part 2]

Limited gains with HRT alone (BFRBs). The TLC guidelines note HRT yields short-term gains that are harder to sustain on its own; add stimulus control, ComB-guided strategies, ACT or DBT enhancements. [source: TLC 2016]

Severe tics or physical injury. Coordinate with the client's physician or neurologist; HRT can run alongside medical treatment [synthesis]. Medication options are outside this guide.

Skin damage or infection from picking. Encourage medical review of wounds; protective coverings double as barriers (4.9) [synthesis].

Sources

Sources: