Habit Reversal Training for BFRBs

HRT is a behavioural approach that combines awareness training, and use of an alternative and incompatible behaviour, to eliminate hair pulling and skin picking. By bringing into awareness all aspects that precede the pull/pick (triggers), including thoughts, sensations, urges, behaviours, and emotions, the adult is better able to recognize that the pull/pick is about to occur. Yet rather than allow it to occur, as soon as the individual becomes aware, s/he learns to immediately engage in a competing response. A competing response (CR) is a behaviour that is incompatible with the pull or pick, such as clenching one’s fists or sitting on one’s hands. When this combination of increased awareness and use of a CR is done every time the pull/pick would otherwise occur, the cycle weakens. A useful analogy is tending a garden- If you spend a little time every week pulling weeds as they appear, the garden progresses and you’ll prevent a weed infestation. Using the tools as soon as you notice urges and early warning signs, the easier it will be to control or stop your urges, and to reduce and eventually eliminate your pulling/picking. However, it becomes much harder to use your tools effectively if you wait until you have a bald spot or skin lesions. To learn and engage in HRT, follow these steps:

  1. Collect information about what happens both internally and externally prior to each pull/pick. Take a sheet of paper and record what you were thinking, feeling, doing, any sensations you experienced, and any other important details that occurred right before the pull/pick.
  2. On the reverse side of the paper write out all the details to a pull/pick incident. Record the sensations you felt as you pulled/picked, emotions you experienced, thoughts, actions (e.g., playing with the hair prior to pulling), and any other important information during the pull/pick incident.
  3. Based on the above information develop 1-3 warning signs that best predict a pull/pick is imminent. For example, a tingling sensation on the scalp and a lightness in the hand.
  4. Begin to pay attention to these warning signs. You can use a pad and paper to check off each time you catch a warning sign.
  5. Develop a competing response you would be willing to do rather than pull/pick. This is an intentional movement that makes it impossible for the pull/pick to occur. Ensure your alternative behaviour is easy to do, subtle, and socially acceptable. Common examples include clenching both hands into a fist, sitting on hands, holding a pen/pencil, or keeping hands in pockets.
  6. Choose a relaxing action that you can do while engaging in your CR, to shift your focus away from the urge and onto your CR. For example, slow deep breathing, use of a pleasant image like soft rainfall or a gentle ocean current, or a body-scan of your muscles. Pairing a relaxing action with your CR can also help to reduce the tension that usually accompanies urges.
  7. Start implementing your CR every time you notice a warning sign. Instead of pulling/picking, engage in the CRs for two minutes, or until the urge to pull/pick passes.
  8. Once your awareness is improved, each time you detect your warning sign/s, engage in your CR. Do this each and every time you encounter and urge to pull/pick.

If you find your awareness has lapsed and you catch yourself in the middle of a pull/pick episode, stop immediately. Engage in your CR.