Habit reversal and ComB: how therapy can help with skin picking and hair pulling

What HRT involves

HRT typically includes awareness training, learning an individually chosen competing response, and supportive involvement from others when wanted. A competing response is a suitable action that makes the target behavior difficult to perform at that moment.

A clinician should select and teach that response. Online descriptions are not a reason to grip, restrain or physically stop another person's hands. Supporters should agree whether a discreet reminder is helpful, rather than watching constantly.

Source context: TLC Foundation: HRT and other behavioral therapies for BFRBs

What ComB adds

ComB develops a personalized understanding of the sensory, thinking, emotional, movement and environmental factors connected with pulling or picking. The clinician then matches strategies to those needs instead of expecting one technique to fit everyone.

For example, boredom during an activity, a particular skin texture and an urge to make something feel smooth may each need consideration. The same visible behavior can have several contributing factors.

Source context: International OCD Foundation: ComB for skin picking and hair pulling

What sessions and practice can look like

The work is collaborative and specific to the person.

1. Notice without judging

   Identify times, places, sensations and actions linked to the behavior, including occasions when awareness is low.

2. Choose a tailored strategy

   A clinician teaches a suitable response and discusses helpful changes to the activity or environment.

3. Practice with agreed support

   Try the selected strategy in relevant situations. Family involvement and reminders are negotiated.

4. Review and adapt

   Look at what helped, physical wellbeing and interference with daily life. Adjust strategies when the pattern changes.

Source context: TLC Foundation: HRT and other behavioral therapies for BFRBs · International OCD Foundation: ComB for skin picking and hair pulling

A fictional example: picking while watching a show

A person notices skin damage after watching television, often without remembering each episode of picking. In therapy, they explore where their hands rest, what they notice on their skin and whether boredom or tension is involved.

The clinician may help them develop an appropriate alternative response and change the setup for that activity. A family member asks whether the person wants a reminder or would prefer privacy. No particular hand position or sensory object works for everyone.

Early progress could be noticing the pattern sooner. Longer-term improvement might include less damage, fewer interruptions and more confidence using the plan. Recurrence is a reason to review the support, not a reason for punishment.

Source context: International OCD Foundation: ComB for skin picking and hair pulling

How this differs from ERP and CBIT

BFRBs are grouped among OCD-related disorders, but they are not automatically OCD compulsions. ERP targets an obsession–compulsion cycle; HRT and ComB address patterns involved in pulling or picking. Assessment determines what is present.

CBIT also includes habit-reversal skills, but is a broader treatment designed for tics. Harmless autistic stimming is another distinct consideration. Similar appearance does not justify using one treatment for all repetitive behavior.

Source context: International OCD Foundation: body-focused repetitive behaviors · CDC: behavioral treatment for tics · National Autistic Society: repeated movements and stimming

Physical care and treatment fit

Get medical advice for wounds, infection, significant hair or skin damage, or other physical concerns alongside behavioral treatment. Therapy should not delay necessary physical care.

HRT has substantial research support among BFRB treatments; ComB is a structured approach with a growing evidence base. Benefit varies. Ask about the provider's experience with the specific behavior, age group and communication needs.

• How will you tell whether this is a BFRB, OCD, a tic or another health issue?
• How will we adapt strategies to the person's sensory and physical needs?
• What should family members do—and what should we leave to the person?
• What will progress look like beyond visible appearance?

• Support for skin picking and hair pulling →
• Compare therapy types →

Source context: TLC Foundation: HRT and other behavioral therapies for BFRBs