How to Deliver Video Habit Reversal Training for BFRBs
How can clinicians structure therapist-delivered video habit reversal training for patients with trichotillomania or excoriation disorder?
Patients with trichotillomania and excoriation disorder often have limited access to trained clinicians despite evidence that habit reversal training can reduce symptoms. This guide applies to clinicians using remote care who need a practical, article-supported way to organize video-based HRT for children, adolescents, and adults.
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Confirm the BFRB diagnosis during the initial evaluation
Conduct the initial evaluation over the first 2 sessions. In the study, therapists used the Diagnostic Interview for Anxiety, Mood, and Obsessive-Compulsive and Related Neuropsychiatric Disorders and proceeded with treatment when patients met DSM-5 criteria for trichotillomania or excoriation disorder. Patients rated as having extreme symptom severity were typically referred to more intensive treatment options.
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Plan a structured video HRT course
Deliver 60-minute HRT sessions by HIPAA-compliant video over approximately 12 to 17 weeks. In this sample, treatment duration and session frequency were individualized, and some patients later transitioned to 30-minute check-in sessions based on clinical progress, symptom reduction, and mastery of HRT principles.
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Teach the core HRT components
Build treatment around awareness training, competing response training, generalization training, and social support procedures. The article describes HRT as helping patients recognize pulling or picking urges and behaviors and replace them with incompatible behaviors when urges arise.
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Add stimulus-focused and functional strategies when indicated
Occasionally incorporate stimulus control strategies and functional analysis of the BFRB as complements to the core HRT components. The study describes these as optional additions rather than universal elements of every session.
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Use between-session digital supports
Offer in-app messaging with the therapist and a mobile app for tracking, with optional access to moderated community and support resources. In the study, these supports were available alongside therapy, and patient engagement with messaging was very high.
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Adapt delivery for youth developmentally
Use age-appropriate language and examples when treating children and adolescents. Vary parental involvement according to the child's age and developmental level, involve parents more actively in treatment planning and skill practice for younger children, and coordinate with other adults such as teachers when clinically indicated.
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Adjust intensity based on ongoing clinical progress
Continue to individualize duration and visit frequency according to symptom reduction and HRT skill mastery. In this real-world sample, care was often less than weekly, with a median of 7 visits through week 16 and an overall median of 11 total visits, and greater session exposure was associated with lower symptom severity in both disorders.
Clinical Considerations
- This was a retrospective observational study without a control group or randomization, so the article does not establish that video HRT caused the observed improvement.
- The study did not include formal treatment fidelity assessment, so it could not verify which HRT components were delivered in each session.
- Video format may limit visual assessment of hair-pulling sites and skin damage, which can affect monitoring of severity and progress.
- Patients with extreme symptom severity were typically referred to more intensive treatment options rather than managed within this model.
Bottom Line
A practical article-supported remote HRT model is a 12 to 17 week video-based course centered on awareness training, competing responses, generalization, and social support, with optional digital messaging and developmentally tailored adaptations for youth.
