“Don’t Touch Your Face!” The Contribution of Habit Reversal in the COVID-19 Pandemic

The Habit Reversal Training (HRT) is a behavioral procedure for treating the so-called nervous habits, such as nail biting, hair pulling and thumb sucking. In addition to being an established clinical procedure, HRT is also a strategy for behavioral change that can serve the entire community. For this reason, this review aims to explore the studies proposing the use of HRT for the reduction of hand-to-face habits in the context of COVID-19 pandemic. Touching one’s nose, mouth and eyes, indeed, is one of the means of virus transmission that many awareness campaigns seek to highlight. After an overview of how HRT works and of the current epidemiological situation, studies supporting Habit Reversal Training for the reduction of risky hand-to-face habits are presented. The possible strategies are then exposed and critically discussed to identify their limitations and propose a new version according to the Relational Frame Theory.
1. Azrin NH, Nunn RG. Habit-reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy. 1973;11(4):619-628. doi:10.1016/0005-7967(73)90119-8
2. Azrin NH, Nunn RG. A rapid method of eliminating stuttering by a regulated breathing approach. Behaviour Research and Therapy. 1974;12(4):279-286. doi:10.1016/0005-7967(74)90002-3
3. Azrin NH, Nunn RG, Frantz SE. Habit reversal vs. Negative practice treatment of nervous tics. Behavior Therapy. 1980;11(2):169-178. doi:10.1016/s0005-7894(80)80017-7
4. Garry M, Pear J. Strategie e Tecniche per Il Cambiamento. 6th ed. McGraw-Hill Education; 2000.
5. Miltenberger RG, Fuqua RW, Woods DW. APPLYING BEHAVIOR ANALYSIS TO CLINICAL PROBLEMS: REVIEW AND ANALYSIS OF HABIT REVERSAL. Journal of Applied Behavior Analysis. 1998;31(3):447-469. doi:10.1901/jaba.1998.31-447
6. Ferrão YA, Miguel E, Stein DJ. Tourette’s syndrome, trichotillomania, and obsessive–compulsive disorder: How closely are they related? Psychiatry Research. 2009;170(1):32-42. doi:10.1016/j.psychres.2008.06.008
7. Morris SH, Zickgraf HF, Dingfelder HE, Franklin ME. Habit reversal training in trichotillomania: guide for the clinician. Expert Rev Neurother. 2013;13(9):1069-1077. doi:10.1586/14737175.2013.827477
8. Liu S, Li Y, Cui Y. Review of habit reversal training for tic disorders. Pediatr Invest. 2020;4(2):127-132. doi:10.1002/ped4.12190
9. Mouton SG, Stanley MA. Habit Reversal Training for trichotillomania: A group approach. Cognitive and Behavior Practice. 1996;3(1):159-182. doi:10.1016/s1077-7229(96)80036-8
10. NCT01445444. Habit Reversal Training for Children and Adolescents With Trichotillomania. Published 2011. https://clinicaltrials.gov/show/NCT01445444
11. Carr JE, Chong IM. Habit reversal treatment of tic disorders: A methodological critique of the literature. Behav Modif. 2005;29(6):858-875. doi:10.1177/0145445505279238
12. Dutta N, Cavanna AE. The effectiveness of habit reversal therapy in the treatment of Tourette syndrome and other chronic tic disorders: A systematic review. Functional Neurology. 2013;28(1). doi:10.11138/FNeur/2013.28.1.007
13. Elliott AJ, Miltenberger RG, Rapp J, Long ES, McDonald R. Brief application of simplified habit reversal to treat stuttering in children. Journal of Behavior Therapy and Experimental Psychiatry. 1998;29(4):289-302. doi:10.1016/s0005-7916(98)00034-2
14. Pawlik B, Perrin CJ. Reducing speech disfluencies during public speaking using brief habit reversal. Journal of Applied Behavior Analysis. 2020;53(2). doi:10.1002/jaba.627
15. Daunton A, Bridgett C, Goulding JMR. Habit reversal for refractory atopic dermatitis: A review. Br J Dermatol. 2016;174(3):657-659. doi:10.1111/bjd.14176
16. Shah R. Habit Reversal Therapy. In: Psychodermatology in Clinical Practice. Springer International Publishing; 2021:383-388. doi:10.1007/978-3-030-54307-5_28
17. Himle MB, Woods DW, Piacentini JC, Walkup JT. Brief review of habit reversal training for Tourette syndrome. J Child Neurol. 2006;21(8):719-725. doi:10.1177/08830738060210080101
18. Yu L, Li Y, Zhang J, et al. The therapeutic effect of habit reversal training for Tourette syndrome: a meta-analysis of randomized control trials. Expert Review of Neurotherapeutics. 2020;20(11):1189-1196. doi:10.1080/14737175.2020.1826933
19. Lochner C, Roos A, Stein DJ. Excoriation (skin-picking) disorder: A systematic review of treatment options. Neuropsychiatric Disease and Treatment. 2017;13:1867-1872. doi:10.2147/ndt.s121138
20. Thompson BL. Is ACT-Informed Exposure a Viable Treatment for Excoriation Disorder? A Multiple Baseline Study. Behav Modif. 2022;2022:014544552210917. doi:10.1177/01454455221091778
21. Nissen JB, Kaergaard M, Laursen L, Parner E, Thomsen PH. Combined habit reversal training and exposure response prevention in a group setting compared to individual training: a randomized controlled clinical trial. Eur Child Adolesc Psychiatry. 2019;28(1):57-68. doi:10.1007/s00787-018-1187-z
22. Shareh H. A Preliminary Investigation of Metacognitive Therapy and Habit Reversal as a Treatment for Trichotillomania. Behav Cogn Psychother. 2018;46(1):1-20. doi:10.1017/s1352465817000546
23. Capriotti MR, Ely LJ, Snorrason I, Woods DW. Acceptance-enhanced behavior therapy for excoriation (Skin-Picking) disorder in adults: A clinical case series. Cognitive and Behavioral Practice. 2015;22(2):230-239. doi:10.1016/j.cbpra.2014.01.008
24. Skinner BF. Beyond freedom and dignity. In: Essays and Reviews: 1959-2002. ; 2014. doi:10.2307/447202
25. Italian National Institute of Health (Istituto Superiore di Sanità). Coronavirus. Published 2020. Accessed June 19, 2022. https://www.epicentro.iss.it/coronavirus/
26. World Health Organization (WHO). Coronavirus disease (COVID-19). Published 2020. Accessed June 19, 2022. https://www.who.int/health-topics/coronavirus#tab=tab_1
27. Kwok YLA, Gralton J, McLaws ML. Face touching: A frequent habit that has implications for hand hygiene. American Journal of Infection Control. 2015;43(2):112-114. doi:10.1016/j.ajic.2014.10.015
28. Elder NC, Sawyer W, Pallerla H, Khaja S, Blacker M. Hand hygiene and face touching in family medicine offices: A Cincinnati Area Research and Improvement Group (CARInG) network study. Journal of the American Board of Family Medicine. 2014;27(3):339-346. doi:10.3122/jabfm.2014.03.130242
29. Macias AE, de la Torre A, Moreno-Espinosa S, Leal PE, Bourlon MT, Ruiz-Palacios GM. Controlling the novel A (H1N1) influenza virus: don’t touch your face! Journal of Hospital Infection. 2009;73(3):280-281. doi:10.1016/j.jhin.2009.06.017
30. Álvarez-Pomar L, Rojas-Galeano S. Impact of Personal Protection Habits on the Spread of Pandemics: Insights from an Agent-Based Model. The Scientific World Journal. 2021;2021:1-14. doi:10.1155/2021/6616654
31. Foss ML, Benike MM, McCoy JR, et al. Hand hygiene: Using positive reinforcement to create new hand hygiene habits. Transfusion (Paris). 2009;49.
32. Heinicke MR, Stiede JT, Miltenberger RG, Woods DW. Reducing risky behavior with habit reversal: A review of behavioral strategies to reduce habitual hand‐to‐head behavior. Jnl of Applied Behav Analysis. 2020;53(3):1225-1236. doi:10.1002/jaba.745
33. Bate KS, Malouff JM, Thorsteinsson ET, Bhullar N. The efficacy of habit reversal therapy for tics, habit disorders, and stuttering: A meta-analytic review. Clinical Psychology Review. 2011;31(5):865-871. doi:10.1016/j.cpr.2011.03.013
34. Clerk AM. Attempting a change in human behavior in ICU in COVID era: Handle with care…!! Indian Journal of Critical Care Medicine. 2020;24(8):626-627. doi:10.5005/jp-journals-10071-2539
35. Wang C, Pan R, Wan X, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. International Journal of Environmental Research and Public Health. 2020;17(5):1729. doi:10.3390/ijerph17051729
36. Park CL, Russell BS, Fendrich M, Finkelstein-Fox L, Hutchison M, Becker J. Americans’ COVID-19 Stress, Coping, and Adherence to CDC Guidelines. Journal of General Internal Medicine. 2020;35(8):2296-2303. doi:10.1007/s11606-020-05898-9
37. Pépin JL, Bruno RM, Yang RY, et al. Wearable activity trackers for monitoring adherence to home confinement during the COVID-19 pandemic worldwide: Data aggregation and analysis. J Med Internet Res. 2020;22(6):e19787. doi:10.2196/19787
38. Harvey AG, Armstrong CC, Callaway CA, Gumport NB, Gasperetti CE. COVID-19 Prevention via the Science of Habit Formation. Curr Dir Psychol Sci. 2021;30(2):174-180. doi:10.1177/0963721421992028
39. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology. 1983;51(3):390-395. doi:10.1037/0022-006x.51.3.390
40. Moderato P. Coronavirus: il rispetto delle regole dal punto di vista dello psicologo. Published 2020. Accessed June 19, 2022. https://www.medicalfacts.it/2020/03/26/coronavirus-il-rispetto-delle-regole-visto-dal-punto-di-vista-dello-psicologo/?fbclid=IwAR0JlBZ6Ws5kGVNvb4qj0rroKdAXxIksBJsuHIiw79cqdLbO0sAbHC2GsC8
41. McLaren RM, Solomon DH. Relational Framing Theory. In: Engaging Theories in Interpersonal Communication. Routledge; 2021:76-88. doi:10.4324/9781003195511-7