Some Habit History
Habits, habit behaviors, or habit disorders are often defined as repetitive, body-focused behaviors that serve no adaptive function and are often unwanted due to the stress or functional impairment they cause (Hansen, Tishelman, Hawking, & Doepke, 1990; Bate, Malouff, Thorsteinsson, & Bhullar, 2011). Such behaviors include: nail-biting, hair pulling (trichotillomania), skin picking, and teeth grinding (Miltenberger, Fuqua, & Woods, 1998); though other behavior such as saying “um” during pauses while speaking in public can be addressed within the same “habit” framework (Mancuso & Miltenberger, 2016). Prior to 1973, leading treatments of habit disorders included psychotherapy, drug interventions, shock-aversion therapy, and negative practice (Azrin & Nunn, 1973). These treatments vary in effectiveness and, in some cases, were not the most humane forms of behavioral intervention as they relied on punishment procedures. As such, several of these treatment approaches would not be used today. Fortunately, an effective approach to treating habits was developed and published by Azrin and Nunn in 1973.
Steps to Habit Change
Azrin and Nunn (1973) built on the work of Butcher (1968) who argued that nervous habits are maintained through operant reinforcement. In conceptualizing habits this way, Azrin and Nunn developed a five step treatment approach and recruited 12 participants to see if it worked. The intervention took place over The results were astounding. Of the 12 participants, 10 of them displayed an average of zero habit behaviors three weeks after treatment had concluded. The seven participants who remained in the study for all follow-up activities collectively showed a 99% reduction in habit behavior at five months post treatment. The procedures used by Azrin and Nunn (1973) are described as steps below and can be utilized in your own life.
- Self-Monitoring: To begin, the individual changing the habit selects a way of counting how often the habit behavior is occurring. This could be an exact count of each time it is happening or a statement regarding the percentage of time each day that the habit behavior is occurring. Various recording strategies can be used depending on individual preference.
- Awareness Training: In this step, the individual changing the habit systematically increases their ability to detect when the behavior is occurring. Several separate systems for this are described by Azrin and Nunn (1973):
- a.) Response Description Procedure: The individual is asked to describe in detail, perhaps using a mirror if necessary, each part of the behavior while engaging in the behavior; attaching the language to the movements.
- b.) Response Detection Procedure: A third party informs the individual when the behavior is occurring and assists the individual in recognizing the behavior (e.g. a third party alerts the individual when their hand is in their mouth).
- c.) Early Warning Procedure: The individual practices detecting the earliest sign of the habit behavior (e.g. when a nail biter first begins to move the hand closer to their mouth).
- d.) Competing Response Practice: The individual is asked to tense the muscles involved in the habit behavior and, in doing so, consequently stop the habit behavior from occurring (e.g. as the individual moves the fingertips towards the mouth, the individual instead tenses the muscles along the length of the arm stopping the motion towards the mouth).
- e.) Situation Awareness Training: The individual is asked to recall all situations, persons, and places where the habit has occurred or is likely to occur and what the habit looks like in that setting (e.g. the individual describes how they put their head down to bite their nails discreetly in a public setting).
- Competing Response Practice: This builds on option “d” in Step 2. In this step, the individual selects a response that is incompatible with the habit behavior and includes all or some of the following characteristics:
- a.) The movement is opposite that of the habit behavior (e.g. moving the hand away from the mouth rather than towards for nail-biting).
- b.) The movement can be maintained for several minutes (e.g. holding an object tightly or pressing the hand into the leg rather than having it near the mouth for nail-biting).
- c.) The movement results in muscles tensing and increasing awareness of the muscles involved in the movement (e.g. clenching fist of the hand that has been moved away from the mouth for nail-biting).
- d.) The movement is inconspicuous in a public setting and allows for continued engagement in daily activities (e.g. the clenched fist of the hand away from the mouth is placed in the pocket of the individual for nail-biting).
- e.) The muscles involved in the movement are strengthened through some level of exercise (e.g. grip strengthening exercises for nail-biting).
- f.) The individual should engage in the competing behavior for three minutes every time s/he experiences the temptation to engage in the habit behavior and when s/he catches him-/herself engaging in the habit behavior. The Azrin and Nunn (1973) article provide some specific examples of competing behaviors for various nervous tics on pages 624-625.
- Habit Control Motivation: This step involves several strategies to increase the individual’s motivation to actively engage in the Awareness and Competing Response pieces of the intervention. These strategies may be implemented by the individual or by a third party involved in the intervention and include:
- a.) Habit Inconvenience Review: In this strategy, the individual reviews any embarrassment or inconveniences that that habit has resulted in. This strengthens the motivation to avoid embarrassment or inconvenience by either not engaging in the habit behavior or by engaging in the competing behavior.
- b.) Social Support Procedure: In this strategy, family and friends of the individual strengthen the motivation by 1.) commenting favorably on efforts when habit-free periods are noted, 2.) offering reminders to “practice your exercises” when habits are overlooked by the individual, 3.) having a third party offer praise for the individual’s efforts at inhibiting habits.
- c.) Special Procedures with Children who are not motivated: Parents either physically guided their children through the competing behaviors upon observing a habit behavior or instructed the child to practice the competing behavior in a bedroom if they failed to self-initiate the competing behavior.
- Generalization Training: This step involves practicing the awareness and competing behavior steps in approximations of the natural settings that the individual spends time in. In some cases, these approximations only need to be imagined. Again, several procedures are available, including:
- a.) Symbolic Rehearsal Procedure: In this strategy, the individual imagines common and habit-eliciting settings and that s/he has just engaged in the start of a habit behavior. The individual then engages in the appropriate competing response as if s/he had actually displayed the habit behavior.
- b.) Additional Practice (Procedure not specified): In this strategy, the individual discusses topics that do not relate to habit behaviors with a third party, simulating an everyday conversation. When the individual begins to initiate a habit behavior, they will detect this and engage in the competing response. The third party is a confederate and will offer a subtle sign to the participant if s/he does not engage in the competing response after initiating the habit behavior.
Currently, the field of Applied Behavior Analysis (ABA) is often considered synonymous with interventions related to autism and intellectual disabilities. Habit Reversal Training deviates from this common association and demonstrates the application of ABA outside of “traditional” populations (Rapp et al., 1998; Twohig & Woods, 2001). The application of Habit Reversal Training also extends across countries and languages such as seen in the work on Nail Biting by Singal and Daulatabad (2017) in India. Finally, it is recognized as a competitive treatment for habit behaviors and is acknowledged as such by practitioners outside of the field of ABA (see Schumer, Bartley, and Bloch’s article in the Journal of Clinical Psychopharmacology (2016) comparing the effects of pharmacological and behavioral interventions).
Disclaimer: While the strategies discussed above can be adapted and implemented in a self-monitoring approach, the use of “third-party” throughout the Blog references a clinician in the original study by Azrin and Nunn (1973). While the information provided offers a framework for decreasing habit behaviors, working with a professional skilled in habit reversal and behavior change is recommended.
Let’s make a habit of continued dialogue between QBS and you. See you again soon!
Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A method of eliminating nervous habits and tics. Behavior Research and Therapy, 11, 619-628.
Bate, K. S., Malouff, J. M., Thosteinsson, E. T., & Bhullar, N. (2011). The efficacy of habit reversal therapy for tics, habit disorders, and stuttering: A meta-analytic review. Clinical Psychology Review, 31, 865-871.
Bucher, B. D. (1968). A pocket-portable shock device with application to nail biting. Behavior Research and Therapy, 6, 389-392.
Hansen, D. J., Tishelman, A. C., Hawking, R. P., & Doepke, K. J. (1990). Habits with potential as disorders: Prevalence, severity, and other characteristics among college students. Behavior Modification, 14, 66-80.
Mancuso, C. & Miltenberger, R. G. (2016). Using habit reversal to decrease filled pauses in public speaking. Journal of Applied Behavior Analysis, 49(1), 188-192.
Miltenberger, R. G., Fuqua, R. W., & Woods, D. W. (1998). Applying behavior analysis to clinical problems: Review and analysis of habit reversal. Journal of Applied Behavior Analysis, 31(3), 447-469.
Rapp, J. T., Miltenberger, R. G., Long, E. S., Elliott, A. J., & Lumley, W. A. (1998). Simplified habit reversal treatment for chronic hair pulling in three adolescents: A clinical replication with direct observation. Journal of Applied Behavior Analysis, 31(2), 299-302.
Schumer, M. C., Bartley, C. A., & Bloch, M. H. (2016). Systematic review of pharmacological and behavioral treatments for skin picking disorder. Journal of Clinical Psychopharmacology, 36(2), 147-152.
Singal, A. & Daulatabad, D. (2017). Nail tic disorders: Manifestations, pathogenesis and management. Indian journal of Dermatology, Venereology, and Leprology, 87(1), 19-26.
Twohig, M. P. & Woods, D. W. (2001). Habit reversal as a treatment for chronic skin picking in typically developing adult male siblings. Journal of Applied Behavior Analysis, 34(2), 217-220.
Keywords: habit disorders, habit reversal training, hair pulling, skin picking, self-monitoring