How Habit Reversal Training Works for Tics

Habit reversal training treats a tic by teaching two skills: noticing the sensation that builds just before it, and pairing that sensation with a different, deliberate movement held long enough for the urge to pass. It is the core technique inside the wider treatment package clinicians call comprehensive behavioural intervention for tics (CBIT), and understanding the mechanism is what makes it possible to actually use, rather than just knowing the name.

This guide assumes you already know what tics are and how they typically change over childhood; our overview of Tourette syndrome covers that ground. Here the focus is narrower and more practical: how the technique works, step by step, and how to start.

What is the premonitory urge

The premonitory urge is the uncomfortable, building sensation that arrives just before a tic, most often described as being close to the feeling right before a sneeze: a tightening, an itch in one specific spot, or a rising pressure that only the tic seems to release. It is not the same as an emotion or a thought. It is a physical sensation, usually localised to wherever the tic occurs, and it is the single most important thing to understand before trying any technique aimed at tics.

The urge typically becomes reliably noticeable somewhere between the ages of eight and ten, which is one reason habit reversal training is rarely attempted with very young children: a five-year-old often has the tic without yet having the words, or the introspective skill, to describe what came before it. An older child, teenager or adult can usually learn to locate it with practice, even if they had never paid attention to it before being asked to.

The urge is also why a tic can be held in for a while and then released all at once, the pattern many families notice where a child holds tics through a school day and lets them go the moment they get home. Suppressing the urge does not make it disappear. It builds, and eventually it is discharged, which is exactly the mechanism habit reversal training is built to interrupt earlier and more deliberately.

How does awareness training work

Awareness training is the first stage of habit reversal training, and its job is narrow: teach a person to reliably notice two things as they happen, the premonitory urge building and the tic itself occurring. Until both can be caught in the moment rather than reconstructed afterwards, there is nothing for the second stage to interrupt.

In practice this starts with description, not intervention. A person describes the tic in detail, out loud or in writing: which muscles move, in what order, how it starts and how it ends. This sounds like a strange first step for something that is meant to reduce a movement, but it works because most people have never actually watched their own tic happen; they know it exists the way you know a habit exists, as a fact about yourself rather than an observed event.

From there, awareness training usually adds simple, low-effort self-monitoring: a tally mark each time the tic happens over a day, or a brief note of what was happening just before it. A mirror or a short phone video can help with tics that are hard to feel directly, such as ones on the face. None of this requires a clinic visit to start. A parent or an adult working on their own tic can begin the same way this week: pick one tic, watch for it deliberately for a few days, and start noticing whether a sensation shows up in the second or two before it does.

How does competing response training work

Competing response training is the second stage, and it is where the actual behaviour change happens: once the urge or the tic is reliably noticed, it gets paired with a different, voluntary movement that is physically incompatible with the tic and is held for roughly a minute, or until the urge passes, whichever is longer. Held long enough, the urge subsides on its own without the tic ever happening, and repeating that pairing is what gradually weakens the link between the two.

A competing response has to satisfy three things to work well. It has to be physically impossible to do at the same time as the tic, which is what “competing” means here. It has to be something the person can hold steadily rather than something brief. And ideally it should be inconspicuous enough to use in a classroom or meeting, since a technique that draws its own attention gets abandoned. A shoulder-shrug tic might be met with gently pressing both arms straight down at the sides. An eye-blink tic might be met with a slow, controlled, sustained closing of the eyes rather than a blink. A throat-clearing vocal tic might be met with slow, controlled breathing through the nose with the mouth closed. The exact movement matters less than the three conditions above; a therapist trained in CBIT will usually tailor one to the specific tic rather than reuse a generic list.

The order matters. The urge or the tic is noticed first, using the skill from awareness training, and the competing response follows it, held for the stretch of time the urge takes to fade. Doing the competing response on a fixed schedule, unconnected to the urge, is a different exercise and not the technique that has trial evidence behind it.

Are tics voluntary or involuntary

Neither claim on its own holds up. Tics are not simply involuntary reflexes that leave no room for anything to help, because most people can suppress them for a period, at a rising cost in effort and attention. They are also not simply voluntary movements someone could stop by choosing to, because “just stop” is a request that can be granted for a few minutes at most, and pushing on it tends to make the urge build faster rather than resolve it.

The reality sits between those two positions, and that middle ground is exactly why habit reversal training works where willpower alone does not. A tic is not chosen the way a decision to raise a hand is chosen, but it is also not entirely automatic the way a knee-jerk reflex is automatic; it runs through an urge that a person can learn to notice and can learn to answer with something other than the tic. Willpower alone tries to fight the urge head-on and loses, because suppression without release just delays the tic and adds discomfort. Habit reversal training does not ask anyone to fight the urge. It gives the urge somewhere else to go.

Does habit reversal training actually work

Yes, and the evidence is unusually solid for a behavioural technique. A randomised, observer-blind controlled trial published in JAMA assigned 126 children with Tourette or a chronic tic disorder to either eight sessions of behaviour therapy or a control condition of supportive therapy and education, and found significantly greater improvement in tic severity in the behaviour therapy group. [piacentini-2010-cbit] A later meta-analysis pooling eight randomised controlled trials of behaviour therapy for tic disorders, comprising 438 participants in total, found a medium to large effect for behaviour therapy relative to comparison conditions. [mcguire-2014-meta-analysis]

The core technique traces back further than either of those. Azrin and Nunn first described habit reversal as a method for eliminating nervous habits and tics in 1973, built around exactly the two components covered above: increasing awareness of the habit, and training a competing response to interrupt it. [azrin-nunn-1973-habit-reversal] Everything since has refined and tested that original idea rather than replacing it.

How to start practicing it

Start with one tic, not all of them. Trying to apply this to every tic at once makes it hard to tell whether anything is working and is a common reason people give up early. Pick whichever tic is causing the most trouble, whether that is discomfort, social difficulty, or interference with something specific like reading or sleep.

Spend a few days on awareness alone before adding anything else. Notice when the tic happens, what tends to come just before it, and whether a specific sensation shows up in that gap. Writing it down, even briefly, makes the pattern easier to see than trying to hold it in memory.

Once the urge is reasonably easy to catch, choose one competing response for that specific tic, one that is physically incompatible with it and can be held steadily. Practice it in short, low-pressure sessions using the timer above before relying on it in a harder moment like a classroom or a meeting. Expect this to take real practice over weeks, not a single sitting; the trial evidence above was built on structured sessions across ten weeks, not one afternoon.

No self-report screener on this site, or elsewhere that we are aware of, is built for tics or Tourette syndrome specifically. If a co-occurring difficulty like anxiety is also part of the picture, our self-assessment hub lists what is available, but it is not a substitute for an assessment of the tics themselves.

When to seek help

Speak to a doctor if tics are causing pain or injury, are creating real social difficulty, or are interfering with school, work or sleep. It is also worth raising this specifically as a topic at an appointment, by name, if you want to learn habit reversal training properly rather than relying on self-guided practice alone: a therapist trained in CBIT can assess which tics to target first, tailor a competing response to each one, and troubleshoot the parts that do not work on paper, which is where most self-taught attempts stall.

How MyFreud can help

MyFreud is not a replacement for CBIT delivered by a trained therapist, and nothing here diagnoses anything. What it can help with is the part that runs alongside formal treatment: tracking which tics show up, how often, and what seems to make a difference over weeks, which is exactly the kind of detail that makes a follow-up appointment more useful than a general update.

Download MyFreud and start today: App Store or Google Play.