Habit Reversal Training (HRT) for Trichotillomania

If you pull your hair, or your child does, you’ll keep coming across habit reversal training. It’s the approach with the most research behind it for trichotillomania (trich), and it sits at the centre of most therapy for hair pulling.

This guide walks through each step, shows what a competing response looks like in real life, and sets out what the studies found in adults, in children and in self-help.

What is Habit Reversal Training (HRT)?

Habit reversal training is a behavioural therapy that teaches you to catch the moment you’re about to pull and to do something else with your hands instead. It doesn’t try to find a single deep cause. It works on the pulling itself, step by practical step.

Behavioural therapy means changing what you do, through practice, rather than only talking about how you feel. The psychologists Azrin and Nunn first described habit reversal in 1973, in a study that included nail biting and eyelash picking. It has since become the main approach for trichotillomania. The UK’s National Health Service (NHS) says trich is commonly treated with it.

Trich is a body-focused repetitive behaviour (BFRB), one of a group of conditions where people repeatedly pull, pick or bite at their hair, skin or nails. Despite the therapy’s name, trich isn’t a bad habit, a lack of willpower or self-harm. Habit reversal treats pulling as a learned pattern your brain runs on autopilot, and gives you tools to interrupt it.

What are the steps of habit reversal training?

Habit reversal training has four main parts: awareness training, a competing response, changing your surroundings, and support from someone you trust. A practitioner usually teaches them in that order over several sessions, and you practise them every day between sessions.

Step	What it means	What you do
1. Awareness training	Learning exactly when, where and how you pull	Track each pull, and learn the earliest signs your hand is about to move
2. Competing response	A harmless action that stops your hands pulling	Do it as soon as you notice a warning sign, for about a minute
3. Changing your surroundings	Making pulling harder or less rewarding	Cover mirrors, move tweezers, change where you sit or what you hold
4. Social support	Someone who encourages you, kindly	They praise your efforts and, if you agree, gently point out warning signs

Notice, respond, change the setting, get support: the four parts of habit reversal.

Awareness training (sometimes called noticing training) comes first, because you can’t change what you don’t notice. You record each pull: where you were, what you were doing, how you felt and which hand you used. With a practitioner, you also practise spotting the first small movements, such as your hand starting to rise. A 2015 review found these early movements are the most reliable warning signs. There’s more on the two ways people pull in our guide to focused and automatic pulling.

Changing your surroundings (often called stimulus control) makes pulling harder to start and less rewarding: covering mirrors, getting rid of tweezers, limiting time in the bathroom. Our guide on how to stop pulling your hair has many more ideas, grouped by trigger.

Social support means one person, often a partner, friend or parent, who praises you for using your competing response and, only if you’ve agreed, points out warning signs calmly. They are never there to watch, tell you off or punish you.

What is a competing response?

A competing response is a simple action you do with your hands that makes pulling impossible for a while. You use it the moment you notice an urge or a warning sign, and you hold it for about a minute, or until the urge fades, whichever takes longer.

A good competing response is:

Physically incompatible with pulling. You can’t do both at once.
Easy to do anywhere, sitting or standing.
Unnoticeable to others, so you can use it in class, at work or on a bus.

Common choices are making gentle fists, pressing your palms flat on your thighs, sitting on your hands, putting your hands in your pockets, folding your arms, or holding a pen, smooth stone or fidget.

A competing response keeps your hands busy for about a minute, or until the urge passes.

The minute matters. Urges tend to rise, peak and fade if you don’t act on them, and holding your competing response gives the urge time to pass. Some people choose one that gives their fingers a feeling close to pulling, such as a textured fidget. Our guide to fidget toys and tools matches tools to the sensations people look for.

Does habit reversal training work?

Yes, for many people. Habit reversal training has more research behind it than any other approach for trichotillomania, and trials consistently find it reduces pulling more than no treatment. It doesn’t work for everyone, and pulling can come back.

Study	Who took part	What it found
McGuire et al., 2014 (review)	11 randomised trials	Behaviour therapy had large effects on pulling, bigger than those of a group of antidepressants called serotonin reuptake inhibitors. More therapy time went with bigger effects
Lee et al., 2019 (review)	Eight habit reversal trials in trich	Every trial found less pulling with habit reversal than without it, though many trials were small or poorly reported
Rogers et al., 2014	60 adults	After a self-help step, then 8 weekly sessions with a therapist, half improved reliably and about a third improved enough to count as a clinically meaningful change
Fisak et al., 2026 (review)	Around 30 trials of therapy and medicine	Therapies that included habit reversal did better than those without it. Habit reversal combined with acceptance and commitment therapy was among the best-supported options

Acceptance and commitment therapy (ACT) is a talking therapy that teaches you to make room for difficult urges and feelings without acting on them. The 2014 review also found that trials which added skills for handling emotions did better than habit reversal alone.

A 2015 review noted the limits: some people improve only a little, some find their pulling creeps back afterwards, and few studies have followed people beyond six months. Setbacks are part of trich, not proof that the therapy failed. Our guide to handling a relapse explains how to get back on track.

How long does habit reversal training take?

Most therapy based on habit reversal runs for about 8 to 12 weekly sessions, with daily practice in between. The trials described in this guide mostly used 8 weekly sessions.

Everyone is different. The Cleveland Clinic, a large US hospital group, says some people succeed within a couple of months while others need a year or more. More therapy time tends to help more. Some programmes add a few top-up sessions after the main course, and in one children’s trial, gains held through that phase.

Can I do habit reversal training myself?

Yes, you can learn and use the steps yourself, and self-help is a good place to start. The research suggests, though, that habit reversal usually helps more when a trained practitioner guides you through it.

Self-help versions come in books, websites and apps, and walk you through the same steps on your own. Here is what the studies found:

Online self-help. A 2025 study followed more than 2,200 people using StopPulling.com, a self-guided website for tracking pulling and choosing strategies. Of the 912 who finished it, 38% cut their symptoms by more than a third. Those who tracked more often did better.
Self-help, then therapy. In the 2014 stepped-care trial (start with the lighter option, move to more support if needed), 60 adults used the same website for 10 weeks. It helped a little. Most then chose 8 sessions of habit reversal with a therapist, which helped much more.
Therapist time. The 2014 review linked more therapist time with bigger improvements, and the 2015 review concluded that one-to-one therapy appears to work best.

So self-help can make a real difference, and the skills carry over to whatever you do next. If you’ve practised steadily for a couple of months and you’re stuck, working with someone who understands trich is a sensible next step. A simple way to start on your own is with our free hair-pulling habit tracker.

Does habit reversal training work for children?

Yes. Habit reversal training is the main therapy used for children and teenagers who pull, and the two trials in young people found good results. Both were small, so more research is needed.

Franklin et al., 2011: 24 children and teenagers aged 7 to 17. After 8 weekly sessions of behaviour therapy built on awareness training, competing responses and changing surroundings, 75% were rated much or very much improved, compared with none of the comparison group.
Rahman et al., 2017: 40 young people aged 7 to 17. After 8 weekly sessions of habit reversal, 76% responded to treatment, compared with 21% of those receiving their usual care. The gains held at a three-month check.

For children, a parent usually takes the support role, as a coach rather than an enforcer. That means praising efforts, helping set up the home and never punishing pulling. Our guide to talking to your child about hair pulling has words that help.

If you’re a parent, The Parent’s Guide to Trichotillomania can help you with understanding what your child is going through.

How is habit reversal different from CBT and the ComB model?

Habit reversal training is usually described as a type of cognitive behavioural therapy (CBT), and it often sits inside a wider plan. The differences are mostly about what gets added around it.

CBT is a talking therapy that looks at how your thoughts, feelings and actions affect each other. For trich, it often includes habit reversal plus work on thoughts like “I’ve ruined it anyway, so I might as well keep going”. Our guide to CBT for trichotillomania explains how it works.
The ComB model (comprehensive behavioural model) maps what drives your pulling (sensations, thoughts, feelings, movements and places) and matches a strategy to each, tailoring habit reversal’s ideas more closely to you. Read more in our guide to the ComB model.
ACT-enhanced habit reversal adds the acceptance skills described above.

For an overview of every approach, including medication and what the evidence says for each, see our guide to trichotillomania treatment.

When should I get help?

Get support if pulling is upsetting you, taking up a lot of your time, or affecting your work, school or relationships, or if self-help hasn’t changed much after a couple of months. You don’t need to wait until it’s “bad enough”.

Many doctors and therapists have never worked with someone who pulls, so it helps to find someone who has. Everyone in our directory has told us they understand trichotillomania and already help people who pull, in person or online. You can search the directory near you. Our guide to finding someone who understands trich explains what to ask on a first call. You can also read more about trich itself in our complete guide to trichotillomania.

If you’re feeling very low or hopeless, please talk to someone today.

In an emergency, call 995 or go to your nearest emergency department.

Samaritans of Singapore (SOS) — 1767 (24h)
IMH Mental Health Helpline — 6389 2222

Questions people ask

Is HRT the same as hormone replacement therapy?

No. In trichotillomania, HRT stands for Habit Reversal Training, a talking and practice-based therapy. It has nothing to do with hormones. Because the letters are shared, it helps to say the full name when you ask a doctor or practitioner about it.

What if my competing response doesn’t stop the urge?

Hold it for longer, or until the urge eases, then give your hands something else to do. A competing response isn’t meant to make the urge vanish. It gets you through the moment without pulling. If one response doesn’t suit you, a practitioner can help you find another.

Can habit reversal training be done online?

Many practitioners offer sessions by video, and the skills are the same: noticing, competing responses, changing your surroundings and support. Most trials have tested in-person therapy, though online self-help programmes based on the same ideas have also been studied.

Will my pulling come back after HRT?

It can. Studies that followed people up after therapy found some pulling returned for many of them. Setbacks are common and don’t mean the therapy failed. Keeping up your skills, and going back for a few top-up sessions if you need them, helps.

Can habit reversal help with skin picking or nail biting too?

Yes, it’s used for other body-focused repetitive behaviours as well. The very first habit reversal study, in 1973, included nail biting, and the same steps of noticing and responding apply. Many people who pull also pick or bite, and a practitioner can work on both.

Do I need a diagnosis before I start?

You don’t need a formal diagnosis to start learning the skills yourself. A practitioner will usually ask detailed questions about your pulling in the first session. If you’re unsure whether what you do is trichotillomania, a doctor can help rule out other causes of hair loss.