Helping Teens Break Free: Using Habit Reversal Training (HRT) to Treat BFRBs in Adolescents
Hair pulling, skin picking, nail biting—these are just a few examples of Body-Focused Repetitive Behaviors (BFRBs), a category of mental health conditions that often begin in adolescence. These behaviors can cause emotional distress, social withdrawal, and even physical injury.
While teens may feel like they can’t stop, there is a powerful, research-based treatment that helps them take back control: Habit Reversal Training (HRT).
What Are BFRBs?
BFRBs are repetitive self-grooming behaviors that result in physical damage to the body and are often triggered by internal cues like anxiety, boredom, or the need for perfection.
Common BFRBs include:
Hair pulling (Trichotillomania)
Skin picking (Excoriation disorder)
Nail or cuticle biting
Cheek or lip chewing
Teens might pull while reading, scroll and pick during screen time, or bite their nails during exams—often without even noticing.
Why HRT Works for Teens
Habit Reversal Training (HRT) is one of the most effective behavioral treatments for BFRBs. It was originally developed in the 1970s and remains a gold-standard intervention. HRT is especially well-suited for adolescents because it:
Is skills-based and practical
Builds self-awareness and autonomy
Empowers teens to take control of their behaviors without shame
The 3 Core Components of HRT
HRT includes several structured steps, typically delivered with the support of a trained therapist. Here's how it works:
1. Awareness Training
Before a teen can change the behavior, they need to notice it.
Teens are taught to:
Identify when, where, and why the behavior happens
Learn their unique triggers (e.g., anxiety, boredom, sensory irritation)
Increase moment-to-moment awareness
Tools used:
Behavior tracking logs
“Catch me if you can” games (making it fun to catch the behavior early)
Recording time, place, emotion, and urge intensity
Example:
Maya, age 16, started to notice she picked at her skin more during math class and late at night. Through awareness training, she learned her urges were strongest when she felt mentally stuck or tired.
2. Competing Response Training
Once the behavior is noticed, teens learn to replace it with a new, incompatible action that interrupts the habit.
A competing response must be:
Inconspicuous (can be done in public)
Opposite of the BFRB (prevents damage)
Held for 1–3 minutes or until the urge passes
Examples of competing responses:
Clenching fists
Squeezing a stress ball
Sitting on hands
Playing with a textured object
Folding arms tightly
Example:
When Zach, age 14, felt the urge to pull hair while studying, he practiced clenching his fists and placing them under his thighs while focusing on breathing.
3. Motivation & Support
Changing a deeply ingrained behavior is hard. Teens need encouragement, reinforcement, and consistency.
This part includes:
Reviewing personal reasons to change
Involving parents and caregivers as coaches, not critics
Celebrating small wins and progress
Using visual progress charts or rewards (e.g., sticker trackers, self-care treats)
Parent Tip:
Instead of saying, “Stop picking!”, try, “I see you noticing the urge—that’s awesome. Want to grab your fidget?”
Optional Add-Ons: Comprehensive Behavioral Treatment (ComB) Approach
Many therapists now enhance HRT with the ComB Model, which expands the treatment to include:
Sensory strategies (e.g., lotions, cooling wipes, fidgets)
Cognitive strategies (e.g., reframing perfectionism or shame)
Environmental modifications (e.g., mirror covers, removing tweezers)
Emotional regulation techniques (e.g., grounding, breathwork)
Why HRT Helps Teens Long-Term
It targets the habit loop at its core
It builds confidence and emotional awareness
It’s empowering, showing teens they can respond differently to urges
It’s flexible, adapting to home, school, and social settings
Unlike approaches that focus solely on stopping the behavior, HRT focuses on understanding it—and learning how to respond with compassion and skill.
A Teen Success Story
Case: Olivia, age 13
Olivia had been biting her nails and picking at her cuticles for years. Her fingers were often sore and sometimes bleeding. She felt embarrassed when friends commented or asked if she was nervous.
With her therapist, Olivia:
Kept a daily log of when she bit her nails
Noticed the behavior increased when she was watching YouTube or after fights with her parents
Practiced using a fidget ring and holding a cold water bottle as competing responses
Created a motivation board reminding her of her goals (clearer hands, more confidence)
Involved her parents in cheerleading her progress instead of policing her behavior
After 12 weeks, Olivia’s fingers had healed, and her urges were cut in half. Even more importantly, she felt proud of her ability to manage stress in new ways.
Final Thoughts: Teaching Teens to Take Back Control
BFRBs don’t have to define your teen. With tools like HRT, adolescents can learn to take charge of their behaviors, understand their emotions, and build lifelong skills for managing stress and self-care.
If your teen struggles with hair pulling, skin picking, or another BFRB, reach out to a therapist trained in HRT and adolescent mental health. Early intervention leads to better outcomes—and empowers teens to feel stronger, more in control, and less alone.
