Habit Reversal Therapy for Tics, Skin Picking, and Hair Pulling: Taking Back Control

If you’re reading this, you might be feeling stuck. Maybe you’ve been picking at your skin, pulling your hair, or wrestling with tics. These behaviours can feel uncontrollable—and they often bring shame, frustration, and exhaustion.

I want you to know: we see you. You are valid. And you can learn tools that work.

Habit Reversal Training (HRT) is one of the most effective treatments for these behaviours. It’s not a “quick fix,” but with practice and support, it can help you take back control over these behaviours. In this post, I’ll walk you through what HRT is, how it works for tics, hair-pulling, and skin-picking. We will also review how you can begin using its core steps. I’ll also answer common questions people ask Google or ask me in therapy.

What are tics, hair-pulling, and skin-picking?

A tic is a sudden, rapid, recurrent movement or vocalization. It may feel involuntary or like a strong urge (Clarity CBT & DBT Center, 2023).

Hair-pulling disorder is also known as Trichotillomania. It involves pulling one’s hair, leading to hair loss and distress (Grant et al., 2017).

Skin-picking disorder is also known as Excoriation Disorder. It involves picking one’s skin, leading to wounds, scars, or significant distress (Grant et al., 2017).

These behaviours often fall under the umbrella of body-focused repetitive behaviours (BFRBs). They don’t mean you’re weak or lazy. They’re often responses to urges, tension, or sensory/emotional triggers—and they can change (Mansueto & Golomb, 2023).

What is Habit Reversal Training (HRT)?

HRT is a behavioural therapy approach. It helps you become aware of the behaviour, recognise the urge, and then practise a healthy alternative response. The idea is that the more you build awareness and a competing response, the less power the unwanted behaviour has.

Core components include:

• Awareness training. Noticing when the behaviour is about to happen (triggers, sensations, urges) (Shaner et al., 2023).

• Competing responses. Practising a behaviour that is physically incompatible with the unwanted one (Shaner et al., 2023).

• Motivation building. Recognising the cost of the behaviour, your reasons to change, and using support (Azrin & Nunn, 1973).

• Generalisation training. Practising the new responses across different settings so the change sticks (Shaner et al., 2023).

Research shows HRT is a first-line treatment for hair-pulling and skin-picking. HRT also supports tic disorders when used as part of larger frameworks like Comprehensive Behavioral Intervention for Tics (CBIT) (McGuire et al., 2017; Piacentini et al., 2010). Learn more about CBIT for Tics.

How HRT helps with each behaviour

For hair-pulling

When you pull your hair, often there’s an urge, a trigger (stress, boredom, sensory itch), and then the pulling. Awareness training helps you catch the “pull cycle” early. One trial found HRT significantly reduced hair-pulling severity in adolescents (Teng et al., 2006).

For skin-picking

Similarly, skin-picking often happens unconsciously (watching TV, stressing, feeling an itch). Sometimes it can feel good in the moment. But it leads to hurt skin and shame. HRT helps you identify that initial moment, substitute a response (like clenching your fists or using a stress-ball), and reduce the picking (Shaner et al., 2023).

For tics

Tics may involve a pre-monitory urge (a build-up of tension) and then the tic happens. HRT/CBIT help by increasing awareness of when the urge begins. Then, you do a “competing response”. This might be holding your body still or redirecting – to reduce the tic’s frequency (Clarity CBT & DBT Center, 2023).

Step-by-step: How to start HRT

You can begin this work with a therapist, or you can self-lead aspects of it while you find a professional. Here are the steps:

1. Track your behaviour

Use a simple log: When did I pick/pull/tic? What was happening? What did I feel just before? Record for a week or two to identify patterns (time of day, setting, mood). Awareness is key: “I’m about to pick” is your signal.

2. Identify triggers and warning signs

Ask: What usually comes just before the behaviour? For example, stress, sitting alone, seeing loose hair, or feeling bored. What physical sensations or thoughts show up? (“My fingers are creeping toward my scalp,” “I feel an itch under my skin.”) Write those down. The more specific, the better. This is supported by research showing awareness training is critical (Shaner et al., 2023).

3. Develop a competing response

Pick a behaviour that is incompatible with the one you’re trying to change. Examples:

• Clench your fists for 30–60 seconds instead of picking.

• Sit on your hands or hold a small object.

• If you feel a tic coming, hold your posture for 1–2 seconds before letting it go.

It should be easy, discreet, and do-able in most settings. Practise it when you feel the urge—not after the action. The goal: do the competing response before the unwanted behaviour (Shaner et al., 2023).

4. Build motivation & support

Write down what the behaviour costs you: shame, skin damage, hair loss, social isolation. Write down what you gain by reducing it: more freedom, less stress, better self-esteem. Share your goals with someone you trust. Ask for gentle check-ins. Celebrate small wins (you didn’t pick for 10 minutes, you caught the urge early).

5. Generalise your skills

Practise your competing response in different places: home, work, travelling, bedtime. When you notice you’re slipping back into old patterns, revisit step 1 (tracking) and adjust your plan. This helps ensure the change sticks across the board.

Frequently Asked Questions (FAQ): HRT

How long will it take to see results?

There’s no magic number. Some people notice changes within a few weeks of consistent tracking and practice. For instance, one study with youth found significant improvement after eight weekly sessions of HRT (Teng et al., 2006). But it’s a journey—not an overnight fix. Expect some ups and downs.

What happens if I relapse or pick/pull after doing so well?

Relapse doesn’t mean failure. The behaviour you’re targeting has been reinforced (often unconsciously) for years. Treat relapse as information: What triggered it? What warning signs did you miss? Use it to strengthen your next plan. Compassion matters here.

Is HRT enough, or do I need medication?

HRT is considered first-line therapy for hair-pulling and skin-picking (Grant et al., 2017). However, each person is unique. Some will benefit from therapy plus medication or other interventions, especially if there are co-occurring conditions like anxiety or depression.

Can I do HRT on my own?

Yes, you can start on your own—but guidance from a therapist improves success. Recent studies show self-help techniques (for example, decoupling) have mixed results compared with full HRT programs (Snorrason et al., 2021). If you go self-led, be honest with yourself, track carefully, and reach out for help if you feel overwhelmed.

Why didn’t HRT work for me?

There are several reasons:

• You might be missing early warning signs.

• Your competing response may not be strong enough or done early enough.

• The environment (stress, triggers) might be too strong without other supports.

• You may require broader support (emotion regulation, trauma work, sensory interventions).

When HRT alone isn’t enough, combining it with other therapies—such as Acceptance and Commitment Therapy or Cognitive Behavioural Therapy—can help (McGuire et al., 2017).

Tips to Make HRT Work

• Start small. Don’t aim for perfection. If you reduce the behaviour by 30% this month, that matters.

• Use reminders. A note on your mirror: “Notice the urge.” Or set a phone alarm to pause and check in.

• Use visuals or logs. A simple chart helps you see patterns.

• Modify your environment. If you pick when watching TV, keep your hands busy (e.g., hold a stress-ball). If you pull hair in bed, keep a beanie or head covering nearby.

• Track your wins. “Yesterday I noticed the urge and used my competing response.”

• Be kind to yourself. Progress isn’t linear. Treat yourself as you’d treat a friend in this process.

When to Seek Professional Support

If you answer yes to any of these, reaching out for professional help is smart:

• The behaviour causes significant distress, shame, or social withdrawal.

• You spend more than an hour per day picking/pulling, or the behaviours leave wounds, scars, or bald spots.

• You have other mental-health concerns (anxiety, depression, trauma) that make it hard to do the steps above.

• You tried HRT-like strategies and saw little to no reduction.

Therapists trained in HRT and BFRBs can tailor the work to you. They can help you identify hidden triggers and build advanced competing responses. A therapist can also help with building motivation and help you stay on track.

How Virtual CBT Can Help You

At Virtual CBT, we specialize in behavioural interventions that feel human—not mechanical. If you’re ready to work on tics, skin-picking, or hair-pulling, we:

• Offer a safe, compassionate space where you are heard.

• Work through HRT step-by-step, adapted for your unique triggers and strengths.

• Help you build emergency plans for when urges spike.

• Collaborate with you on environment changes and stronger competing responses.

• Move at your pace. We know change takes time.

Get Started with an HRT Therapist Today

Let’s start now. Pick one small step today—maybe it’s tracking your picking or pulling for the next 24 hours. Then get in touch with us. Book a free consultation or send us a message. At Virtual CBT, you don’t have to face this alone. We’re ready when you’re ready.

Book a free consultation with Virtual CBT, and take back control. Our Clinical Directors will match you with a registered therapist.

You deserve relief. You deserve support. Let’s walk this path together.

Learn about our therapy fees.

Written by Amy Battistone, RSW, MSW

References

Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11(4), 619-628.

Clarity CBT & DBT Center. (2023). Habit reversal training overview. New York, NY: Author.

Grant, J. E., Chamberlain, S. R., Redden, S. A., Leppink, E. W., Odlaug, B. L., & Kim, S. W. (2017). N-acetylcysteine in the treatment of excoriation disorder: A randomized clinical trial. JAMA Psychiatry, 74(7), 760-767.

Mansueto, C. S., & Golomb, R. G. (2023). Comprehensive behavioral (ComB) model for skin-picking and hair-pulling disorders. International OCD Foundation Expert Opinions Series.

McGuire, J. F., Ung, D., Selles, R. R., Rahman, O., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2017). Treating trichotillomania and excoriation disorder using habit reversal training: A comprehensive review and meta-analysis. Clinical Psychology Review, 58, 16-29.

Piacentini, J., Woods, D. W., Scahill, L., Wilhelm, S., Peterson, A. L., Chang, S., … Walkup, J. T. (2010). Behavior therapy for children with Tourette disorder: A randomized controlled trial. JAMA, 303(19), 1929-1937.

Shaner, S. M., Van Kampen, D. A., & Li, S. C. (2023). Psychological interventions in body-focused repetitive behaviors: A clinical dermatology review. Clinical Dermatology Review, 7(4), 250-259.

Snorrason, I., Berlin, G. S., Lee, E., & Woods, D. W. (2021). Self-help habit reversal versus decoupling in trichotillomania: A randomized controlled trial. Journal of Obsessive-Compulsive and Related Disorders, 28, 100629.

Teng, E. J., Woods, D. W., Twohig, M. P., & Marcks, B. A. (2006). Body-focused repetitive behavior problems in adolescents: Habit reversal training treatment outcomes. Behavior Modification, 30(6), 896-918.