What Is Habit Reversal Training for Hair Pulling and Skin Picking? And Does It Work?

If you have been researching treatment for trichotillomania or excoriation disorder, you have probably come across the term Habit Reversal Training. Maybe a therapist mentioned it. Maybe you found it in a forum or a clinical article. Either way, you are wondering what it actually involves and whether it is worth pursuing.

Here is a straightforward explanation of what HRT is, what the research says, and what it looks like in practice for hair pulling and skin picking.

What Is Habit Reversal Training?

Habit Reversal Training, commonly called HRT, is a behavioral treatment originally developed in the 1970s by Nathan Azrin and R. Gregory Nunn. It was designed to treat repetitive behaviors, motor tics, and what we now call body-focused repetitive behaviors, or BFRBs.

HRT is not talk therapy. It does not focus on processing the emotions behind the behavior or exploring why it started. It focuses on the behavior itself — making it visible, understanding its triggers and function, and replacing it with a competing action.

It is considered a first-line treatment for trichotillomania and excoriation disorder by most clinical guidelines.

How Does HRT Work?

HRT has three core components. These are not steps you do once and move on from. They work together as a practice.

Awareness training

Most people who pull their hair or pick their skin do it automatically. The behavior runs without conscious attention, which is exactly why trying to stop it with willpower does not work. Awareness training is the process of making the behavior visible — learning to notice when it is happening, what comes right before it, and what the body feels like in the moment before the urge takes over.

This usually involves self-monitoring: tracking episodes, triggers, emotional states, physical sensations, and what the behavior delivers in the moment. The goal is not accountability. The goal is data.

Competing response

A competing response is a behavior that is physically incompatible with pulling or picking. When the hands are doing something else, they cannot be in the hair or on the skin.

The competing response has to be specific and matched to the function of the behavior. This is where a lot of generic self-help advice falls short. Telling someone to keep their hands busy does not work if the behavior is driven by a specific sensory sensation, a perfectionism urge, or emotional dysregulation. The competing response has to address what the nervous system is actually seeking.

For example: if hair pulling is triggered by the sensation of a coarse or out-of-place hair, a competing response might involve a scalp massager, a fine-tooth comb, or a cooling roller applied to the scalp. If skin picking is driven by tension and anxiety, a competing response might involve clenching both fists, applying lotion to both hands, or wearing compression gloves.

Deliberate practice

This is the component most self-help approaches leave out entirely. Reading about competing responses does not change the behavioral loop. Practicing the competing response reactively, after the behavior has already started, is too late.

Deliberate practice means creating the trigger conditions on purpose, letting the urge build, and using the competing response while the urge is present. This is the same mechanism as exposure and response prevention. You are not trying to eliminate the urge. You are teaching the nervous system that the urge does not have to result in the behavior.

Every time you outlast an urge without acting on it, the urge weakens slightly. Every time you act on it, the loop strengthens. Deliberate practice is how you shift that ratio.

Does Habit Reversal Training Actually Work for Hair Pulling and Skin Picking?

The short answer is yes, with caveats.

HRT has strong research support for trichotillomania and excoriation disorder. Multiple randomized controlled trials have shown it to be effective at reducing pulling and picking behavior. A 2010 study published in the Journal of Consulting and Clinical Psychology found HRT significantly outperformed a waitlist control for trichotillomania. Similar findings exist for skin picking.

HRT is also the foundation of Comprehensive Behavioral Treatment, or ComB, which is a newer approach that expands on HRT by mapping interventions more precisely to the specific sensory, emotional, cognitive, and environmental triggers driving the behavior. ComB is increasingly considered the gold standard for BFRB treatment.

The caveats are real though. HRT requires consistent practice. It does not work if you read about it without doing the actual work. Outcomes are better with a trained therapist than with self-guided work alone, though self-guided structured practice does show benefit, particularly for people who cannot access a specialist.

What HRT Is Not

HRT is not about eliminating the urge to pull or pick. The urge is not the problem. The urge is information from your nervous system. The goal is to change what you do with it.

HRT is also not about white-knuckling through the urge. If you are gritting your teeth and trying to force yourself not to pull, that is not HRT. That is willpower, and it does not generalize. HRT is about giving the nervous system something it can actually use instead.

And HRT is not a quick fix. The behavioral loop took a long time to build. Rebuilding it takes consistent practice, usually over weeks to months. Progress is not linear. A setback is not a failure. It is data about where the loop still has a function.

How to Get Started With HRT

If you want to work with a therapist trained in HRT or ComB for BFRBs, the TLC Foundation for BFRBs maintains a therapist directory at bfrb.org. If you are in North Carolina or New York and want to work with a specialist, you can reach out at mentalhealthissexy.org.

If you want to start doing structured self-guided work now, the This Isn't a Habit workbook walks you through every component of Habit Reversal Training for hair pulling and skin picking. Awareness training, trigger and function mapping, personalized competing responses matched to your specific sensory and emotional triggers, deliberate practice sessions, and a long-term maintenance protocol. Built by Madina Alam, LMHC, a licensed therapist who specializes in OCD, anxiety, and BFRBs.

Available at mentalhealthissexy.org/store.

For more on understanding why hair pulling and skin picking are so hard to stop, read: Why You Can't Stop Pulling Your Hair or Picking Your Skin.

For a practical step-by-step guide, read: How to Stop Hair Pulling and Skin Picking at Home.