Competing Response Training

Description of the Strategy

Competing response training (CRT; also, competing reaction training) is a primary component of habit reversal training (HRT), a treatment package most commonly used to reduce undesirable or maladaptive repetitive behaviors, including tics, stuttering, and habit disorders. CRT consists of teaching a competing response, which is applied contingent upon occurrence of the target behavior or any urge to engage in the target behavior for 1 to 3 minutes. Historically, the competing response has been an alternative behavior incompatible with production of the target behavior, involving isometric tensing of the same muscles in the opposite direction used to produce the target behavior. For example, CRT may consist of teaching a client to replace an undesirable response such as hair pulling with a more desirable alternative, “competing” response, such as clenching fists for 2 minutes. More recent applications have been less strict, deemphasizing tensing of opposite muscles and occasionally selecting unrelated alternative behaviors, particularly in treatment of young children. Common competing responses include such actions as clenching fists, opening and closing hands, tensing neck muscles, regulated deep breathing, crossing arms, placing hands in pockets, and sitting on hands.

HRT was developed in the 1970s and was originally comprised of 9 to 13 separate procedures categorized into four core components: (1) awareness training, (2) CRT, (3) motivational procedures, and (4) generalization procedures. The first component consisted of a set of procedures designed to help the client notice instances of the target behavior. The second component was as described above. The third component involved a set of procedures designed to motivate the client to eliminate the target behavior and to facilitate adherence to recommended treatment components. The final component was aimed at enhancing generalization through symbolic rehearsal of common habit-evoking situations (i.e., imagining a high-risk situation and practicing the competing response).

More recently, studies using habit reversal in the treatment of childhood habit and tic disorders have increasingly applied simplified habit-reversal procedures, generally including three components: awareness training, CRT, and social support procedures. Social support procedures are designed to promote generalization and maintenance efforts by having the child's parents praise the absence of the target behavior, praise independent completion of the competing response, and prompt the child to engage in the competing response (physically assisting as needed) when the target behavior is observed.

Habit reversal and its simplified variants have effectively treated a variety of repetitive behaviors, including various motor tics, stuttering, hair pulling, finger and thumb sucking, fingernail biting, scratching, and [Page 778]destructive oral habits (e.g., lip, mouth, and tongue biting), as well as comorbid habit disorders such as concurrent hair pulling and thumb sucking. Habit reversal has been effective in as little as one 2-hour session. Although studies with young children typically require at least one treatment session followed by two to four shorter booster sessions to obtain desired reductions in the target behavior(s), more intractable problems, such as Tourette's disorder, often require many more sessions to achieve desired outcomes.

Research Basis

CRT, as a standard component of HRT, is backed by 30 years of research across a wide range of clinical problems and a variety of target populations. Several variations of habit reversal have been effective in treating children and adolescents. Nearly all successful variants have included awareness training and CRT, which are considered to be essential components. Yet research focused on treatment of children indicates that social support efforts may also be required to obtain positive outcomes, particularly with young children.

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