Habit reversal was developed by Nathan Azrin and Gregory Nunn in 1973 as a treatment for habit disorders

(nervous habits and tics). Habit reversal was originally developed to treat nervous habits and tics and modified a
year later to treat stuttering.

Habit behaviors occur repeatedly across situations and continue to occur in the absence of social reinforcement.
Nervous habits, also called bodyfocused repetitive behaviors by some authors, consist of repetitive:

 hand-to-head behaviors- such as hair pulling or hair twirling,

 hand-to-mouth behaviors- such as nail biting or thumb/finger sucking,
 hand-to-body behaviors-such as skin picking or scratching, and
 oral behaviors -such as mouth biting or teeth grinding.

There are two types of tics: motor tics and vocal tics.

 Motor tics: consist of rapid, repetitive, jerking movements of muscle groups (e.g., head jerking, facial
grimacing, shoulder shrugging), and
 vocal tics: consist of repetitive sounds and/or words spoken with no communicative function (e.g., throat
clearing, grunting, swear words).

Motor and vocal tics may be part of a diagnosable disorder such as Tourette's disorder.

Stuttering involves disruption in the fluency or timing of speech such as word, syllable, or sound repetition,
prolongation of word sounds, or blocking when attempting to speak.

There are four major components of the habit reversal procedure: awareness training, competing response
training, habit control motivation, and generalization training.

Psychoeducation

Relaxation techniques: The patient was taught progressive muscular relaxation and diaphragmatic breathing and
was asked to do both on a daily basis.

Awareness Training

The goal of awareness training is to teach the child to become aware of each instance of the habit behavior or
the immediate antecedents to the habit behavior. To accomplish this goal, a number of procedures are used.

i)First is response description, in which the child describes all of the behaviors involved in the habit. For
example, if a child engages in hair pulling, the child would describe all of the movements involved in pulling a
hair (e.g., raising the right hand to the scalp, feeling hairs with the fingertips, isolating a hair with the thumb and
index finger, pulling the hair, rolling the hair between the thumb and index finger, and finally dropping the hair
on the floor).

ii)After describing the behavior, the child practices response detection. In this procedure, the therapist helps the
child identify each instance of the habit behavior as it occurs in the session. For behaviors such as tics or
stuttering that would naturally occur in session, the therapist engages the child in conversation and instructs the
child to indicate each time the behavior occurs. For behaviors such as hair pulling, nail biting, or other nervous
habits that typically occur only when the child is alone, the therapist has the child simulate the behavior in
session and identify each occurrence of the behavior.
iii)In the early warning procedure, the therapist works with the child to identify when the behavior is about to
occur. For tics, the child might identify a physical sensation that typically precedes the occurrence of the tic. For
nervous habits, the therapist might help the child identify the initial movements involved in the behavior (e.g.,
beginning to raise a hand to engage in hair pulling). For stuttering, the therapist may help the child identify the
initial sound of a stutter to immediately recognize its occurrence.

iv)The final awareness training procedure is situation awareness training, in which the therapist helps the child
identify each of the situations in which the habit behavior is most likely to occur. For example, tics may be most
likely to occur in stressful situations, nervous habits may be most probable when the child is alone at certain
times, and stuttering may be most likely to occur with specific words or in specific evaluative situations.

II)COMPETING RESPONSE PRACTICE: In competing response practice, the child identifies a behavior that
is incompatible with the habit behavior and engages in this behavior for a few minutes to heighten his or her
awareness of the muscles involved in the habit behavior. For a motor tic, the competing response would involve
tightening the muscles involved in the tic and holding the body part immobile. For a nervous habit involving the
hands, the child might practice making a fist or grasping an object. For stuttering, the competing response is
diaphragmatic breathing with a slight exhale before speaking.

(She was then instructed that whenever and wherever she gets the urge to pull, she was to (in order) relax
herself, do diaphragmatic breathing for 60 seconds, and the competing response for 60 seconds.)

The therapist instructs the child to engage in the competing response for 1 to 3 minutes contingent on the
occurrence of the habit behavior or the antecedents to the habit behavior.

Each time the habit behavior occurs in session and the child uses the competing response, the therapist provides
praise.

If the habit behavior occurs and the child fails to use the competing response, the therapist prompts the child to
engage in the competing response.

The child practices until he or she can successfully engage in the competing response to control the habit
behavior without any further prompting from the therapist. For habits that typically occur only when the child is
alone, the therapist instructs the child to simulate the habit behavior in session and to use the competing
response contingent on its occurrence.

Once the child has demonstrated mastery of the competing response in the treatment session, the therapist
instructs the child to use the competing response for 1 to 3 minutes contingent on the habit behavior or
antecedents to the habit behavior outside the treatment session. To help motivate the child to use the
competing response consistently outside the treatment sessions, the therapist utilizes habit control motivation
procedures.

b) Replacement behaviors including cue-controlled relaxation and postural variations such as not holding
her head in her hand while working or driving; placing her hands behind her head and under the pillow
while lying in bed, watching television were agreed upon for environmental situations in which the
problem behavior was most likely to occur. It was recommended to increase the distance between her
hands and head at all times and hold a pen in whichever hand was idle while she was working.
III)Habit Control Motivation

Three procedures are used to help increase the child's motivation to use the competing response to eliminate the
habit behavior: habit inconvenience review, social support, and public display procedures.

i)In habit inconvenience review, the therapist asks the child (and parent) to describe all the ways in which the
habit behavior has caused inconvenience, embarrassment, or disruption in the child's life. After reviewing the
negative aspects of the habit behavior, the child should be more motivated to carry out treatment procedures to
change the behavior.

ii)In the social support procedure, the therapist enlists the help of a significant other (usually a parent) who
helps the child control the habit behavior. Specifically, the social support person is instructed to (a) praise the
child for using the competing response appropriately, (b) praise the child for the absence of the habit behavior
in situations where the habit typically occurred before treatment, and (c) prompt the child to use the competing
response if the child fails to use the competing response contingent on an instance of the habit behavior.

iii) Finally, in the public display procedure, the therapist instructs the child to demonstrate control of the habit
behavior in session and in the presence of significant others in order to receive social reinforcement for
controlling the habit.

IV)Generalization Training

The final component of habit reversal, generalization training, is intended to promote the use of the competing
response in all relevant situations outside the therapy sessions. To promote the successful use of the competing
response, the therapist has the child practice it in session while providing social support. In addition, the child
engages in symbolic rehearsal and imagines using the competing response successfully and controlling the habit
behavior in everyday situations outside the therapy session.