HRT for BFRBs: How Habit Reversal Training Works

HRT for BFRBs

How Habit Reversal Training Works

Body-Focused Repetitive Behaviors (BFRB) | Habit Reversal Training (HRT) | Therapy San Francisco Bay Area | Mindfulness-Based Therapy

What Are Body-Focused Repetitive Behaviors (BFRBs)?

BFRBs are repetitive behaviors towards one’s own body that cause physical damage or noticeable distress. The most common forms are hair pulling (trichotillomania), skin picking (excoriation disorder), and nail biting. These conditions usually start in early adolescence and are often co-occurring with anxiety or depression. Many people who struggle with BFRBs never seek treatment due to shame or a lack of local providers trained in the proper care.

What Is Habit Reversal Training (HRT)?

Habit Reversal Training is a behavioral method for reducing nervous habits and tics. HRT is the most well-established, evidence-based treatment for BFRBs today. It doesn’t rely on willpower alone to stop the behaviors. HRT teaches clients to recognize the physical sensations and situations that come before a pulling or picking episode, then learn to replace it with a different, harmless action.

The Core Components of HRT

Awareness training. Many people do not notice when they are engaging in BFRBs. They can be triggered during moments of boredom, stress, or focus (like reading or driving). The first phase of HRT builds moment-to-moment awareness of the urge, the behavior itself, and the specific triggers involved. The client learns to identify in detail the specific movements associated with the action and acknowledge each time they do the unwanted behavior. Over time, the client will be able to detect the earliest signs of the unwanted behavior.

Competing response training. Once awareness improves, clients learn a physically incompatible response behavior. The new behavior should make it difficult or impossible to do the unwanted behavior. Examples include clenching a fist, sitting on hands, folding hands, or crossing arms. Clients learn to perform these responses for about a minute whenever the urge arises. Over time, this interrupts the habit loop.

Stimulus control and social support. Therapists often help clients modify their environment (removing tweezers from view, using gloves or fidget tools) and involve supportive friends or family members to gently reinforce progress between sessions.

Finding HRT for BFRBs in San Francisco and the Bay Area

BFRBs respond well to the right kind of structured, skills-based support, but access to therapists trained specifically in HRT is limited, and many providers still lack familiarity with these conditions (Feusner et al., 2026). Our San Francisco practice offers Habit Reversal Training alongside complementary approaches such as ACT and ERP for clients managing trichotillomania, skin picking, nail biting, and related conditions. We offer in-person sessions in San Francisco and telehealth appointments throughout California, so Bay Area residents in Oakland, Marin, and the Peninsula can access evidence-based BFRB treatment without a long commute.

If pulling, picking, or biting has become a source of frustration or shame, know that this is a common and highly treatable pattern. Reach out to schedule a consultation and learn how Habit Reversal Training could work for you.

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.

Bate, K. S., Malouff, J. M., Thorsteinsson, E. T., & Bhullar, N. (2011). The efficacy of habit reversal therapy for tics, habit disorders, and stuttering: A meta-analytic review. Clinical Psychology Review, 31(5), 865–871.

Feusner, J. D., Beatty, C. C., Murphy, C., McGrath, P. B., Farrell, N. R., Nuñez, M., Lume, N., Mohideen, R., Trusky, L., Smith, S. M., & Rhode, A. (2026). Therapist-delivered video therapy habit reversal training for body-focused repetitive behaviors: Clinical outcomes from a large real-world sample of youth and adults. Journal of Clinical Psychiatry, 87(1), Article 25m15834.

Moritz, S., Penney, D., Bruhns, A., Weidinger, S., & Schmotz, S. (2022). Habit reversal training and variants of decoupling for use in body-focused repetitive behaviors: A randomized controlled trial. Cognitive Therapy and Research. Advance online publication. https://doi.org/10.1007/s10608-022-10334-9

Ready to get started with individual therapy in the Bay Area?

mindfulSF offers individual therapy in San Francisco, Oakland, and throughout the Bay Area for anxiety, OCD, depression, trauma, job stress, parenting and more. Online services also offered across California.