CBIT and Habit Reversal Training
Behavioral Treatment for Tics, Tourette's Syndrome, and Body-Focused Repetitive Behaviors
Natalie Noel, LMHC | Anxiety & OCD Treatment Specialists | Tampa, FL
Read More About Our Treatment Modalities
Watching a child or family member struggle with tics or living with them yourself is harder than most people understand. Tics are involuntary. They are not a choice, a nervous habit, or a sign of poor self-control. And for many people with tic disorders and Tourette’s syndrome, the frustration of being told to ‘just stop’ as if willpower were the issue compounds the distress of the tics themselves.
The good news is that there is an evidence-based behavioral treatment that works not by suppressing tics through willpower, but by changing the brain’s learned relationship with the urge that precedes them. That treatment is CBIT Comprehensive Behavioral Intervention for Tics and it is the most effective non-medication treatment for tic disorders currently available.
At Anxiety & OCD Treatment Specialists, we provide CBIT and Habit Reversal Training (HRT) for children, teenagers, and adults with tic disorders and Tourette’s syndrome in person in Tampa, Florida, and virtually across Florida.
In-person sessions are provided in Tampa and virtual sessions are available throughout Florida and New York.
Quick Answer: What Is CBIT?
CBIT stands for Comprehensive Behavioral Intervention for Tics. It is a structured, evidence-based treatment for tic disorders and Tourette’s syndrome that combines Habit Reversal Training (HRT) with psychoeducation, relaxation training, and functional intervention. CBIT works by teaching people to recognize the premonitory urge that precedes a tic and to perform a competing response that is physically incompatible with the tic until the urge passes. With consistent practice, the brain’s automatic transition from urge to tic is interrupted and the tic frequency and intensity decrease. CBIT is recommended as a first-line behavioral treatment for tic disorders by the Tourette Association of America.
What Are Tics and What Causes Them?
Tics are sudden, repetitive, non-rhythmic movements or sounds that feel difficult or impossible to control.
They are divided into two main types:
- Motor tics: Involve movement eye blinking, head jerking, shoulder shrugging, facial grimacing, or more complex coordinated movements.
- Vocal tics: Involve sounds throat clearing, sniffing, grunting, humming, or in some cases words or phrases.
Tics are also classified as simple (brief, sudden, limited to one muscle group) or complex (involving multiple muscle groups in a coordinated sequence, or elaborate vocalizations). Tourette’s syndrome is diagnosed when a person has both motor and vocal tics that have been present for more than a year.
Tic disorders are neurologically based involving differences in the basal ganglia and related circuits that regulate voluntary movement. They are not caused by bad parenting, stress alone, or emotional problems, though stress and fatigue can certainly exacerbate them. Tic disorders have a significant genetic component and are more common in males than females.
The Premonitory Urge Why Tics Feel the Way They Do
One of the most important things to understand about tics and the clinical insight that makes CBIT possible is the premonitory urge. Most people with tic disorders report that tics are preceded by an uncomfortable sensory experience: a building tension, pressure, or ‘not just right’ feeling in the affected body part. The tic temporarily relieves this urge. And then the urge builds again.
This urge-tic-relief cycle is structurally similar to the obsession-compulsion cycle in OCD and CBIT targets it in a structurally similar way. Rather than focusing on the tic itself, CBIT targets the urge. When a person learns to recognize the urge early before the tic fires they can apply a competing response that satisfies the sensory need without performing the tic.
Most people with tic disorders describe the tic as something they have to do not something they choose to do. The premonitory urge is what makes it feel that way. CBIT does not ask people to suppress the urge through willpower. It gives them a behavioral alternative that addresses the urge which is a fundamentally different and far more sustainable approach.
Habit Reversal Training (HRT) The Core of CBIT
Habit Reversal Training is the behavioral foundation of CBIT and has been consistently supported by research across several decades. HRT for tics involves three core components:
The Three Components of HRT
1. Awareness Training
The first step is building precise awareness of the tic when it occurs, what it feels like, what the premonitory urge feels like, and what situations tend to trigger or worsen it. Many people with tics are partially habituated to them and do not notice every occurrence. Awareness training includes self-monitoring exercises and, for children, parent observation. You cannot respond to an urge you have not yet noticed.
2. Competing Response Training
A competing response is a voluntary behavior that is physically incompatible with the tic and can be held for 1 to 3 minutes without significant disruption to daily activity. For a head-jerk tic, the competing response might be slow, deliberate neck muscle isometric tensing contracting the muscles that would prevent the head jerk. For a throat-clearing vocal tic, the competing response might be slow nasal breathing through the nose with the mouth closed. The competing response is held until the premonitory urge passes typically 30 seconds to 3 minutes.
3. Social Support
A parent, partner, or trusted person is taught to provide brief, non-critical prompts when the tic is observed reminding the person to use the competing response. This is particularly important for children, who are still building self-awareness. Social support is warm and collaborative never shaming or punitive.
The Full CBIT Package Beyond HRT
CBIT includes HRT as its central component, but it is a more comprehensive treatment than HRT alone. The additional components address the factors that trigger, worsen, or maintain tic behavior:
Psychoeducation
Both the person with tics and their family receive education about the nature of tic disorders what causes them, how the premonitory urge works, why stress worsens tics, and how CBIT addresses the underlying cycle. This understanding reduces shame, improves engagement with treatment, and equips families to respond to tics in helpful rather than counterproductive ways.
Functional Assessment and Intervention
CBIT includes a careful assessment of the situations, emotions, and contexts that make tics better or worse. For many people, tics are significantly worse in specific situations during homework, while using screens, when anxious or excited, or when attention is directly on the tic. Functional intervention develops specific strategies for managing these high-tic-risk situations changing the environment, restructuring activities, or preparing specific competing response strategies for predictable triggers.
Relaxation Training
Because stress, anxiety, and physical tension consistently worsen tics, relaxation training is included as a standard component of CBIT. Diaphragmatic breathing and progressive muscle relaxation are taught as skills to use both proactively as part of the daily routine and reactively, during high-stress situations where tic worsening is anticipated.
CBIT vs. Medication for Tic Disorders
Medication is available for tic disorders most commonly alpha-2 agonists (guanfacine, clonidine) and antipsychotics (aripiprazole, fluphenazine, haloperidol). For severe tic disorders with significant impairment, medication can be an important part of the treatment picture.
For mild to moderate tic disorders, CBIT alone is often sufficient and is preferred by many patients and families because it produces lasting change without medication side effects. The research comparing CBIT and medication shows comparable efficacy for most presentations with CBIT producing more durable results that persist after treatment ends, and medication requiring ongoing use to maintain benefits.
| Medication for Tics | CBIT for Tics |
|---|---|
| Can reduce tic frequency and severity quickly | Produces gradual improvement over 8 to 12 sessions |
| Requires ongoing use to maintain benefits | Results persist after treatment ends often improving over time |
| Associated with side effects sedation, weight gain, mood changes | No medication side effects; builds self-efficacy and mastery |
| Does not teach self-management skills | Teaches lifelong self-management skills for urge recognition |
| May be necessary for severe or disabling tic disorders | Highly effective for mild to moderate tic disorders |
| Second-line recommendation for mild to moderate tics | First-line recommendation from Tourette Association of America |
HRT for Body-Focused Repetitive Behaviors (BFRBs)
Habit Reversal Training is also the primary behavioral treatment for Body-Focused Repetitive Behaviors (BFRBs) including trichotillomania (hair pulling) and excoriation disorder (skin picking). While BFRBs are categorized differently from tic disorders, they share key features: a sensory urge that precedes the behavior, temporary relief produced by the behavior, and a learned urge-behavior-relief cycle that responds to HRT.
HRT for BFRBs follows the same three-component structure as HRT for tics awareness training, competing response training, and social support adapted for the specific urge-behavior patterns of hair pulling and skin picking. The competing response for a hair-pulling BFRB might involve making a fist or placing the hands flat on the thighs any response that occupies the hands and is incompatible with pulling.
CBIT and HRT Are Both Available at Our Practice
We provide CBIT for tic disorders and Tourette’s syndrome, and HRT for body-focused repetitive behaviors including trichotillomania and excoriation disorder.
Both conditions co-occur frequently with OCD and anxiety disorders, and our team is trained to treat the full clinical picture not just the tic or BFRB in isolation.
CBIT and OCD When They Co-Occur
Tic disorders and OCD co-occur at a significantly higher rate than would be expected by chance estimated at 50% or more in clinical populations with Tourette’s. The co-occurrence has both neurological and clinical implications. OCD in people with Tourette’s tends to have a different profile than OCD in the general population — more often involving symmetry, exactness, and sensory-driven compulsions (‘just right’ OCD) alongside the more typical contamination and harm presentations.
When OCD and tic disorders co-occur, both are addressed in treatment. ERP for the OCD and CBIT for the tics can be delivered in parallel or sequentially depending on which is causing more functional impairment. Our practice is specifically equipped for this combination because we specialize in both.
CBIT for Children What Parents Need to Know
CBIT is highly effective for children and adolescents and the research on pediatric CBIT is among the strongest in the behavioral treatment literature. A landmark NIMH-funded study found that CBIT produced significant tic reduction in children with tic disorders, with results maintained at six-month follow-up.
For children, parent involvement is essential. Parents attend sessions, learn the awareness training and competing response protocol, and provide the social support component at home. For younger children especially, the parent is often the primary driver of the CBIT work coaching the child through competing response practice, observing tics, and providing brief, non-critical reminders.
CBIT is not about making children suppress their tics through effort or shame. A skilled CBIT therapist frames the competing response as a tool the child is gaining something that gives them agency over their tics rather than being controlled by them. This framing matters enormously for children who have experienced shame or frustration around their tics.
What to Expect in CBIT Treatment
- Assessment. A thorough evaluation of the tic profile which tics are present, their frequency and severity, the premonitory urge pattern, co-occurring conditions (OCD, ADHD, anxiety), and the functional impact of tics on daily life.
- Psychoeducation. The person with tics and their family receive a clear explanation of tic disorders, the premonitory urge, and how CBIT works. For children, this includes age-appropriate language and often involves naming the tics and giving the child a sense of agency.
- Awareness training. Building precise awareness of the most impairing tics and the premonitory urge that precedes each one. Self-monitoring assignments are used between sessions.
- Competing response development. A specific, individually tailored competing response is developed for each targeted tic one that is physically incompatible with the tic and can be held inconspicuously in social situations.
- Practice and generalization. Competing responses are practiced in session and assigned for home practice. The functional assessment guides which situations require specific competing response strategies. Social support person is trained.
- Relaxation and functional intervention. Relaxation skills are taught and high-trigger situations are addressed with specific strategies.
- Relapse prevention. Tics can wax and wane throughout life particularly during stress and developmental transitions. Treatment concludes with a clear plan for responding to tic increases and refreshing CBIT skills when needed.
CBIT is typically delivered in 8 to 10 sessions over 10 weeks. The research protocol used in the landmark clinical trials used this structure. Most people see meaningful tic reduction within the first few weeks of completing HRT sessions with active competing response practice.
In-Person and Virtual Sessions
In-person
730 S Sterling Ave, Suite 306, Tampa, FL 33609
Virtual:
Available throughout Florida and New York
CBIT and HRT work effectively via telehealth. Because the competing response practice happens in the person’s real-life environments home, school, work and because parent coaching is a central component for children, virtual delivery offers genuine advantages. Research supports equivalent outcomes for CBIT delivered via video compared to in-person delivery.
Frequently Asked Questions
Can CBIT cure Tourette's syndrome?
CBIT does not cure Tourette’s syndrome tic disorders are neurologically based and may wax and wane throughout life. What CBIT does is significantly reduce tic frequency and severity, reduce the distress and functional impairment caused by tics, and give the person effective tools for managing tic increases when they occur. Many people who complete CBIT experience substantial and lasting improvement with tics that are either minimal or easily managed rather than impairing. The tools learned in treatment remain available throughout life.
My child's school is asking them to suppress tics. Is that appropriate?
No not as a general expectation. Tic suppression is exhausting and not sustainable. It typically produces a rebound increase in tics after the suppression period ends. Schools can and should make reasonable accommodations for students with tic disorders including permission to step out when tics are severe, reduced written work requirements during high-tic periods, and education for peers and teachers about the involuntary nature of tics. CBIT provides a more sustainable approach: not suppression, but self-management through competing responses. We can provide documentation to support school accommodations when needed.
My child has both tics and OCD. Which should be treated first?
This depends on which condition is causing more functional impairment. In many cases, both are treated in an integrated way CBIT for the tics alongside ERP for the OCD. Our practice is specifically trained in both approaches and in the specific profile of OCD that co-occurs with Tourette’s which tends toward sensory-driven, ‘just right’ presentations. A thorough assessment determines the right treatment sequence and structure for your child’s specific situation.
Is CBIT the same as just telling someone to stop their tics?
No and this distinction is critical. Telling someone with a tic disorder to stop is unhelpful and often harmful. It implies that tics are a choice, which they are not. CBIT is not about willpower or suppression. It is a structured behavioral protocol that works with the premonitory urge the sensory experience that precedes the tic rather than trying to override it with effort. The competing response addresses the urge in a way that willpower alone cannot. Most people with tic disorders who complete CBIT describe the experience as gaining genuine control something that feels very different from being told to try harder.
Tics Do Not Have to Be in Charge.
CBIT and HRT give people with tic disorders and BFRBs a concrete, evidence-based path to reducing the frequency and distress of their symptoms and a set of lifelong skills for managing them. At Anxiety & OCD Treatment Specialists, we deliver CBIT with the same specialist rigor we bring to ERP for OCD and CBT for anxiety. If tics or BFRBs are affecting your life or your child’s life, we are ready to help.