995752

research-article2021
PPSXXX10.1177/1745691621995752Harvey et al.Habit Formation and Mental Illness

ASSOCIATION FOR
PSYCHOLOGICAL SCIENCE

Perspectives on Psychological Science

Applying the Science of Habit Formation 2022, Vol. 17(2) 572­–589

© The Author(s) 2021
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DOI: 10.1177/1745691621995752
https://doi.org/10.1177/1745691621995752

Treatments for Mental Illness www.psychologicalscience.org/PPS

Allison G. Harvey , Catherine A. Callaway , Garret G. Zieve,

Nicole B. Gumport, and Courtney C. Armstrong
Department of Psychology, University of California, Berkeley

Abstract
Habits affect nearly every aspect of our physical and mental health. Although the science of habit formation has long
been of interest to psychological scientists across disciplines, we propose that applications to clinical psychological
science have been insufficiently explored. In particular, evidence-based psychological treatments (EBPTs) are
interventions targeting psychological processes that cause and/or maintain mental illness and that have been developed
and evaluated scientifically. An implicit goal of EBPTs is to disrupt unwanted habits and develop desired habits.
However, there has been insufficient attention given to habit-formation principles, theories, and measures in the
development and delivery of EBTPs. Herein we consider whether outcomes following an EBPT would greatly improve
if the basic science of habit formation were more fully leveraged. We distill six ingredients that are central to habit
formation and demonstrate how these ingredients are relevant to EBPTs. We highlight practice points and an agenda
for future research. We propose that there is an urgent need for research to guide the application of the science of
habit formation and disruption to the complex “real-life” habits that are the essence of EBPTs.

Keywords
habit formation, habit disruption, evidence-based psychological treatments (EBPTs), cognitive behavior therapy
(CBT), learning theory

A habit is defined as a learned action that is performed our higher powers of mind will be set free for their
with minimal cognitive effort (Lally & Gardner, 2013; own proper work” ( James, 1899/1983, p. 34). The
W. Wood & Neal, 2007). The importance of habits in behaviorists demonstrated that habits develop and
our everyday lives cannot be overstated. Habits affect are strengthened through repetitions of associative-
every aspect of our physical and mental health, includ- learning and reinforced responses (Hull, 1943; Skinner,
ing our exercise frequency and intensity, when and how 1938; Thorndike, 1998). Cognitive scientists have
we sleep, what we eat, the content and patterning of shown the importance of automaticity in the formation
our thinking, how our attention is allocated and cap- of habits (Schneider & Schiffrin, 1977; Wason & Evans,
tured, whether we tend toward approach or avoidance, 1974). Neuroscience, computational approaches, and
and so forth. Therefore, our habits hold a key to the social and health psychology have also played critical
major health challenges we all face as we attempt to roles in advancing the field. Although the study of
fashion our lives to incorporate healthy habits and habits clearly crosses interdisciplinary boundaries
reduce or—even better—eliminate unhealthy habits (Verplanken & Orbell, 2003; W. Wood, 2017; W. Wood
(Gardner et al., 2019; Verplanken, 2018). & Rünger, 2016), the central concern raised herein is
The science of habits has long been of interest to
psychological scientists. In 1899, William James said
Corresponding Author:
the following about the critical importance of habits: Allison G. Harvey, Department of Psychology, University of California,
“The more of the details of our daily life we can hand Berkeley
over to the effortless custody of automatism, the more Email: [email protected]
Habit Formation and Mental Illness 573

that a­ pplications to clinical psychological science have broader spectrum of EBPTs might improve if we were
been insufficiently explored. to more fully embrace the science of habit formation
The past several decades have been marked by excit- and train providers in these skills.
ing advances in evidence-based psychological treat- There is a great need for naturalistic studies to delin-
ments (EBPTs) for mental illness and a broad range of eate the contributors to knowledge about the multiple
psychological health problems. EBPTs are interventions complex “real-life” habits that are tackled in EBPTs. In
targeting psychological processes that cause and/ the absence of these studies, we can only conjecture
or maintain mental illness and that have been devel- about applications to EBPTs. Nonetheless, possible
oped and evaluated scientifically (Barlow et al., 2013; implications for EBPTs are summarized in Table 1.
Chambless & Hollon, 1998). EBPTs are clearly effective Although points are illustrated with examples from vari-
and are considered to be frontline treatments for many ous EBPTs, most often the examples are drawn from
mental illnesses (Division 12 of the American Psycho- cognitive behavior therapy (CBT) for insomnia (CBT-I;
logical Association, 2016; Layard & Clark, 2014; National Morin & Espie, 2003; Perlis et al., 2005) and other
Institute for Health and Care Excellence, 2020). How- related sleep interventions (Harvey & Buysse, 2017).
ever, there is room for improvement (Kazdin, 2018). In This focus was selected for several reasons: Sleep prob-
this article, we propose that applying the science of lems are highly prevalent, sleep health behaviors are
habit formation to EBPTs may greatly improve out- ideal targets for habit formation, and CBT-I is the front-
comes. It is clear that an implicit goal of many EBPTs line treatment (Qaseem et al., 2016; Riemann et al.,
is to disrupt unwanted habits and to develop new 2017; Trauer et al., 2015). Moreover, the existing litera-
desired habits. However, (a) the extent to which exist- ture on sleep interventions seeks to disrupt several
ing EBPTs can successfully disrupt and build habits is unhelpful habits. For example, sleep problems are often
unknown, and (b) there has been insufficient attention maintained by habits such as irregular bed and wake
given to habit-formation principles, theories, and mea- times, excessive and poorly timed caffeine consumption
sures in the development and application of EBPTs. or technology use, or insufficient or poorly timed light
The goal of this article is to distill ingredients of habit exposure during the day.
formation that could be relevant to EBPTs in a way that
is transdiagnostic (i.e., relevant across disorders) and
pantreatment (i.e., relevant across EBPTs).
Theory
Our motivation for considering a deeper application Although the understanding of habits varies across
of the science of habit formation within clinical psy- scholars and disciplines—and there are ongoing debates
chological science is that many researchers and clini- (Gardner et al., 2012; Trafimow, 2018; W. Wood &
cians consider the process of habit formation to be a Neal, 2007)—the theoretical grounding for this article
“passive phenomenon” or “a ‘natural’ outcome of the was drawn from health psychology because of its con-
behavior change process” rather than a process that can ceptual proximity to clinical psychological science. In
be specifically planned for and guided (Stokes & Baer, the health-psychology literature, habit formation is
1977, p. 349). In contrast, as we make evident, there understood to be a learned process in which a behav-
are clear principles and strategies we can draw from, ior (the habit) becomes paired with a stable context
adapt, and infuse into existing EBPTs to more intention- cue and, via repetition, comes to trigger an automatic
ally incorporate the science of habit formation. There- impulse to engage in the habit (Gardner, 2015). Repeti-
fore, we propose the study of habits is an important, tion reinforces the behavior-context association. Rein-
fertile, creative, and fascinating domain for future forcement motivates and strengthens repetition. With
research. ongoing repetition, the stable context cue becomes
The great potential for leveraging existing knowl- sufficient to activate the association. In other words,
edge on habit formation has already been recognized the context triggers the impulse to perform the behav-
in subfields. For example, habit is included within the ior with minimal cognitive effort or intention, and the
formulation of specific problems, such as depressive habit becomes more automated and less reliant on our
rumination (Watkins, 2018; Watkins & Nolen-Hoeksema, goals (Verplanken, 2018). This definition is depicted
2014), obsessive-compulsive disorder (Gillan et al., graphically in Figure 1. The six elements of habit for-
2014), and hair pulling, tics, nail biting, and skin pick- mation discussed in this article were distilled from this
ing (Azrin & Nunn, 1973). In addition, addictions have theory. Further, this theory depicts the way in which
been conceptualized as habits. However, the concep- the six key elements interact.
tualization of addiction has expanded to recognize a There are two important issues to address before
broader range of issues (Everitt & Robbins, 2016). In proceeding. First, within this theory and throughout
this article, we consider whether the outcomes from a this article, the terms behavior or action are used to
574 Harvey et al.

Table 1. Summary of Habit-Promoting Tips for Providers of Evidence-Based Psychological Treatments

Habits are independent of goals
Goal setting, motivational interviewing, and psychoeducation are initial steps
Within psychoeducation, include education on the building blocks of habit formation
Habits are cued by specific contexts
Set up cues that are salient, accessible, and perceptible
Facilitate the repetition of the desired new habit in a stable context
Set up explicit environmental cues for the habits that patients wish to develop and/or explicitly identify and remove cues for
   habits that patients wish to disrupt
Frame the functional-analysis process as a method to uncover the cues to undesirable habits and to develop new desired habits
Habits are learned via repetition
Measure repetition as part of progress monitoring
Ensure patients engage in sufficient practice/repetition to build new habits
Provide patients with the skills and knowledge to modify the habits that are formed when needed so that repetition and habit
   formation can continue
Use implementation intentions to promote repetition/practice
Provide reminders to engage in repetition/practice
Habits are automatic
Functional analysis and self-monitoring can be used to “unpack” the automatic processes of an unwanted habit
Consider using behavioral experiments
Consider substituting a new more helpful habit in response to the same cues as the unwanted habit; include a theoretical
   rationale for the substitution strategy and for selecting the specific substitute behaviors
Guide patients in conceptualizing and selecting substitute behaviors that are enjoyable and consistent with their values
Implementation intentions can be useful for developing automaticity to the substitute
Measure the development of automaticity as part of progress monitoring
Reinforcers promote habits
For disrupting unwanted habits, use functional analysis to discover reinforcers
Reinforcers may be helpful at the beginning of the habit-formation process
Consider how to optimize the schedule of reinforcement for the habit-formation process
Consider how reinforcers can be delivered after the completion of a course of treatment, such as patient self-delivered
  reinforcers
Examine the impact of reinforcers on a regular basis and modify them according to the individual’s subjective evaluation of the
  reinforcing properties
Build positive associations with the new desired habits
Habits take time to develop
Consider delivering booster sessions to promote habit formation
Consider developing “bundles” of desired behaviors that can be chunked together as the unit for habit formation

refer to the target of habit formation. However, these considered along with potential applications to EBPTs
are used as umbrella terms that refer to and encompass and domains for future research.
a broad array of behavioral, cognitive, and emotional
processes (e.g., Verplanken et al., 2007). Second, within
EBPTs we are concerned with the development of new Habits are independent of goals
habits and the elimination of unwanted habits. For the Habits are typically the result of a goal that individuals
latter, following Gardner and Lally (2018), we use the set and pursued in their past (W. Wood & Neal, 2007).
term habit disruption in recognition of the possibility Indeed, the path to habit formation begins when a
that the processes underlying habits may always remain person repeats a behavior in a specific context in pur-
in place, even if a stronger alternative habit is formed. suit of a goal. Once the habit is established, it tends to
endure and be independent of any new goal that we
Distilling the Elements of Habit set, even if the consequences of the habit are unwanted
and/or have become aversive (de Wit & Dickinson,
Formation 2009; Orbell & Verplanken, 2010). In other words, goals
In this section, the six key aspects of habits that feature and habits can become divergent. A vivid example is
in the habit-formation theory just presented are substance use. A substance might initially be used to
Habit Formation and Mental Illness 575

Repetition Reinforcement Habit Formation

Stable Context
Stable Stable Stable Cue
Context Cue Context Cue Context Cue

Behavior-Context
Association Triggered

Behavior Automatically
Performed
Behavior Behavior Behavior

Fig. 1. Theory of habit formation.

manage social anxiety, to fit in with peers, or for the such as the striatum, particularly the dorsal striatal sys-
hedonic value. Once the use of the substance becomes tem, the medial prefrontal cortex, the caudate nucleus,
habitual it can be hard to disrupt even if the person and regions of the basal ganglia (Balleine & O’Doherty,
desperately wants to quit because of hazardous health 2010; Dezfouli & Balleine, 2012; Graybiel & Smith, 2014;
consequences or difficulty retaining relationships or Smith & Graybiel, 2016; Yin & Knowlton, 2006). For
employment. The goal has changed to “getting my life stronger habits, such as addiction, the anatomy and
back on track,” but this new goal does not easily shift circuitry implicated are similar but also include mid-
the habit. brain dopamine cell groups and limbic parts of the
Indeed, most scholars of habit formation have pallidum (ventral pallidum), the thalamus (mediodorsal
emphasized shifting from goals to habits (Cushman & nucleus), and amygdala (Everitt & Robbins, 2005;
Morris, 2015; Gardner, 2015; W. Wood & Rünger, 2016). Kalivas & Volkow, 2005).
Further, Pittenger and Taylor (2018) reviewed data EBP Ts already encompass several components that
showing that the biologic systems underpinning goal are, at least in part, designed to support patients in
pursuit are adapted for new or complex environments, identifying, clarifying, and pursuing their goals. Specifi-
whereas the systems for habits are adapted to improve cally, goal-setting is a feature of most EBPTs, along with
efficiency but are inflexible. The bottom line is that progress monitoring to track progress toward goals.
when the goal and habit systems are in balance and Motivational interviewing is used to clarify the goal and
used skillfully, people are well equipped to efficiently build the motivation for change (Miller & Rollnick,
navigate the complexities of the various environments 2002). Psychoeducation is typically given to provide
they encounter. However, a failure in the balance information about the benefits of pursuing the chosen
between goals and habits can contribute to “inappro- goal, such as improving sleep-related health, quitting
priately rigid behaviors and a range of psychopathol- smoking, reducing anxiety or depression, and so forth.
ogy” (Pittenger & Taylor, 2018, p. 322). The weekly home practice, common across EBPTs, also
A broad range of approaches within neuroscience, contributes to the repeated practice of goal pursuit.
including animal and human studies, optogenetics, However, EBPTs should go further to recognize that
lesion studies, and the use of chemical inactivation, these are only the very beginning steps and that the
have identified a separation in the brain circuits and additional specific steps, guided by the elements of
systems that are associated with goal-directed versus habits distilled here, are necessary to truly form new
habitual behavior. Across these various approaches, habits and disrupt unwanted habits.
there is consensus that habit formation involves a grad- It is likely that in the popular understanding of habit
ual transition from flexible and goal-directed behavior formation, there is no recognition of the shift from
associated with the prefrontal cortex to brain regions goal-directed behavior to habit. Thus, we should
576 Harvey et al.

provide education within EBPTs on how habits can be which proposes that attempts at behavior change will
formed and disrupted. One EBPT, rumination-focused be more effective if they capitalize on moments of
CBT (RFCBT), incorporates this approach (Watkins, change, such as a change of job, birth of a child, or a
2018). The provider explains the characteristics of rumi- move (Verplanken & Wood, 2006). These are natural
nation as a habit, namely that rumination tends to be life events that involve less contact with powerful old
automatic, is triggered by various cues, will be hard to cues for unwanted habits and that create an opportunity
change, and will recur under conditions of stress or for behavior change. Heatherton and Nichols (1994)
tiredness. The approach also prepares patients for inev- asked participants to write about experiences with suc-
itable setbacks in breaking the rumination habit and cessful or failed life changes (e.g., quitting smoking).
developing new desirable habits. Many of the participants (36%) who had successfully
changed had moved to a new location, whereas only
13% of reports of unsuccess­ful attempts involved mov-
Habits are cued by specific contexts
ing. In addition, 13% of successful-change reports
Habits are formed via the direct association between a involved a change in environmental cues, whereas none
stable contextual cue and a behavior (Fig. 1). Cues can of the unsuccessful reports involved such a shift.
take several forms; they can be internal (e.g., a thought There are multiple burning questions for future
or body sensations), external (e.g., clock time), deliber- research. For patients seeking an EBPT to help them
ate (e.g., making a coffee before sitting down to work), disrupt an unwanted habit, which types of cues are
or inadvertent (e.g., grabbing yet another minidonut easier and which are harder to disrupt? For those seek-
from the box a coworker left in the office; W. Wood & ing to build new desired habits, which types of cues
Rünger, 2016). Note that cues that are salient, accessi- promote efficient habit formation (e.g., internal, exter-
ble, and perceptible are more likely to become associ- nal, event-based, time-based)? Within EBPTs, how do
ated with habits (Gardner & Lally, 2018). we position cues optimally within a set of behaviors
There are certain types of cues that may more pow- that are bundled together in the pursuit of building a
erfully assist in habit formation. Gardner and Lally sequence of new habits?
(2018) proposed that event-based cues (e.g., “after A relevant distinction has been drawn between habit
breakfast”) may be more suitable than time-based cues instigation and habit execution (Gardner et al., 2016,
(e.g., “at 10 a.m.”), which require conscious monitoring. 2020). Habit instigation describes the processes involved
These scholars also point out that although any con- in the selection and initiation of a behavior, such as
textual feature can become a habit cue, some contexts selecting to begin the “wind-down” sequence from all
may be more suited to supporting habit formation than available options and committing to performing it and
others. For example, Pimm et al. (2016) found that taking the first step in the ensuing wind-down sequence
people who consistently exercised with the same peo- before bedtime (e.g., closing the computer and walking
ple, in the same part of their routine, or in the same over to dim the lights). Habit execution refers to the
mood, reported stronger physical-activity habits. Lally processes that contribute to enacting the habit itself (e.g.,
et al. (2010) also showed that when people perform a engaging in the full wind-down sequence). Gardner
behavior repeatedly in the same context (e.g., taking a et al. (2016) reported that measures of habit instigation
walk after dinner), over time the context automatically are more predictive of enacting the desired habitual
triggers the behavior. It is noteworthy that an estab- behavior relative to measures of habit execution. Future
lished habit can serve as a cue to forming a new habit research is needed to determine whether this finding can
( Judah et al., 2013). Judah et al. (2013) compared habit be replicated in the context of EBPTs.
formation among those who were instructed to floss While we await answers from these domains of
after toothbrushing relative to before toothbrushing. future research, consider that most EBPTs include a
Habit formation was stronger for those who flossed functional analysis that involves mapping out the
after toothbrushing. This finding raises the likely impor- sequence of stimuli and responses, which typically
tance of the position of cues within existing “bundles” includes behaviors, cognitions, and emotions, for a
of habits (e.g., nighttime routine). situation of interest. However, explicitly framing the
One path to disrupting unwanted habits is to reduce functional-analysis process as a method for uncover-
the contact with the cues associated with the unwanted ing the cue or cues to undesirable habits and for
behavior by changing the environmental context (Gardner identifying potential cue or cues to developing new
et al., 2019). However, just as habits are easier to build desired habits has the potential to lay a strong foun-
within stable contexts, they are likely to be harder to dation for intervention. For example, in RFCBT, func-
break within stable contexts (Carden & Wood, 2018). tional analysis is used to determine how, when, with
This idea leads us to the habit discontinuity hypothesis, whom, and where the rumination habit does and does
Habit Formation and Mental Illness 577

not occur as well as its antecedents (to spot the warn- with sleeping and not with wakefulness, anxiety, or
ing signs and triggers to the habit) and consequences tossing and turning. For example, insomnia patients are
(Watkins, 2018). asked to go to bed only when sleepy, and if they do
In EBPTs, we often make use of contextual cues not fall to sleep within 15 to 20 min then to go to
by strategically discussing where to place the self- another room until they are really sleepy—and then
monitoring form (e.g., leave the daily sleep diary and return to bed. They repeat this process until they fall
a pen on the breakfast table) and placing cues in the to sleep. Patients are also instructed to use the bed only
environment to remind patients of their homework for sleep and for sex (Bootzin, 1972). Other changes
(e.g., sticky note on the bathroom mirror to remind made to the environment to improve the association
patients of the time they should start their wind-down between bed and sleeping include moving work, study,
routine when they brush their teeth each night). How- and meals to a location that is not the bed.
ever, within EBPTs there is room for a more explicit Furthering our prior discussion on trying to develop
emphasis on setting up environmental cues to help with multiple habits simultaneously, W. Wood and Neal
the formation of new desirable habits that patients wish (2007) noted that performing multiple behaviors in
to develop and a more explicit emphasis on identifying response to a single cue dilutes the mental association
and removing cues for habits that patients wish to dis- between that cue and any one behavior, limiting the
rupt. Once the habit is formed in a stable context, likelihood that a behavior will become habitual. Unfor-
research is needed to determine how to generalize the tunately, EBPTs typically involve multiple complex hab-
habit to other contexts. its. One potential solution is to test whether it is possible
Marteau et al. (2012) drew attention to the relevance to achieve habit formation involving multiple behaviors
of Tolman’s law of least effort, which proposes that we by devising a cue that triggers a tightly coupled bundle
can alter cues in the environment to make the least of behaviors. Consider a teenager whose parent pro-
effortful course the most likely. Applying this law to vides the cue “It’s time to get up for school.” An exam-
EBPTs, we can consider how to position cues to make ple of a desired bundle of behaviors triggered by this
it easy to engage in desired habits and hard to engage cue would be (a) getting out of bed, (b) opening the
in unwanted habits. Relatedly, Rothman et al. (2015) curtains to let sunlight in, (c) making the bed so it is
proposed introducing “behavioral friction” to existing hard to get back in, and (d) taking a shower to promote
contexts that make it harder for people to follow their wakefulness.
unhealthy habits. For example, a common cue for The discussion thus far has focused on removing the
smoking is drinking an alcoholic beverage. When pubs cue. As highlighted earlier, several scholars (W. Wood
in the United Kingdom banned smoking, people could & Neal, 2007; W. Wood & Rünger, 2016) have drawn
no longer smoke while drinking (Orbell & Verplanken, attention to another possibility: inhibiting the habitual
2010), and this disrupted the automated connection response once the cue has activated the habitual behav-
between the cue (drinking) and the behavior (smok- ior. In one application of this process with relevance
ing). Although this was a population-level intervention, to EBPTs, Quinn et al. (2010) demonstrated that “vigi-
behavioral friction could also be incorporated at the lant monitoring” in the form of thinking “Don’t do it”
individual level within EBPTs. Carden and Wood (2018) and watching carefully for slipups was useful for con-
highlighted environmental-reengineering interventions trolling strong habits. However, it is possible that some
that involve changing the structure of everyday deci- types of suppression may trigger a rebound in the
sions. For certain eating disorders, it may be helpful to inhibited unwanted behavior or thought (Wenzlaff &
change the type of food available. Altering the environ- Wegner, 2000), a concern that was raised about “thought-
ment, such as dedicating a prominent place for fruits stopping” approaches for obsessions in obsessive-
and vegetables on the kitchen counter, might also guide compulsive disorder (Purdon, 1999).
people into “rip currents,” potentially leading to a cas-
cade of changes that helps maintain new behaviors,
Habits are learned via repetition
including shifts in identity (e.g., “I am a healthy eater”;
Carden & Wood, 2018). Repetition is a key component in forming a new habit.
Another related approach to altering cues in the As we repeat or practice a behavior, in a stable context,
environment is stimulus control, in which a behavior the habit starts to form, and our intentions and goals
is triggered by the presence or absence of a specific related to that behavior gradually become less influential
cue or set of cues. For example, stimulus control is a (Carden & Wood, 2018). Repetition exerts its effects via
powerful EBPT treating insomnia (Morin et al., 2006). increased pairings between the stimulus and the
Stimulus control for insomnia involves changing the response (Hull, 1943; Skinner, 1938; Thorndike, 1998).
behavior of the sleeper so that the bed is associated Repetition has been proposed to improve skills, ensure
578 Harvey et al.

the behavior is selected with less effort, and automate over 28 weeks. Habit formation, as measured by the
behavior selection (Haith & Krakauer, 2018). SRHI, reached an asymptote at around 19 weeks.
Although various creative designs have been devel- Another study by Fournier, d’Arripe-Longueville,
oped to study habit formation in a laboratory setting Rovere, et al. (2017) investigated the formation of the
with humans (e.g., Daw et al., 2011; de Wit et al., 2012, habit of performing a psoas iliac stretch daily. This
2018; Luque et al., 2019) and animals (for review, see stretch maintains flexibility and prevents lower back
Lerner, 2020), we focus on naturalistic longitudinal pain. Habit formation occurred within 22 weeks. Lally
studies because they provide useful insights into the et al. (2010) asked participants to choose a habit they
amount of repetition or practice that is likely to be would like to form, such as eating healthy foods, drink-
needed to form a habit within EBPTs. For these studies, ing healthy drinks, or engaging in more physical activ-
the outcome measure tends to be the Self-Report Habit ity. Habit formation varied from 18 days to 36 weeks.
Index (SRHI; Verplanken & Orbell, 2003). This measure There are likely multiple timing and other character-
starts with the stem “Behavior X is something . . .”; this istics that influence the amount of repetition needed.
stem is followed by items that assess facets of habit For example, Fournier, d’Arripe-Longueville, Rovere,
formation such as “I do frequently,” “I do automatically,” et al. (2017) reported that habits practiced in the morn-
and “I do without having to consciously remember.” ing were formed more quickly than habits practiced in
The respondent is asked to agree or disagree with each the evening. This finding was mediated by higher morn-
item. A higher score denotes greater habit strength. ing cortisol levels, which have been implicated in the
There are 12-item (Verplanken & Orbell, 2003) and development of habits. The impact of stress and fatigue
seven-item (Lally et al., 2010) versions. In addition, the on repetition and habit formation is also not yet clear,
Self-Report Behavioral Automaticity Index (SRBAI) is a although it is clear that stress and fatigue have strong
four-item measure of automaticity (Gardner et al., effects on habit performance (Neal et al., 2013; Schwabe
2012). & Wolf, 2013). Because stress and fatigue may be a
The handful of longitudinal studies conducted thus characteristic of those seeking an EBPT, the impact on
far, all of which used variants of the SRHI or SRBAI, habit formation is an important domain for future
highlight that (a) repetition is an important part of the research. Another issue relevant to timing is the level
habit-formation process, (b) the amount of repetition of consistency of repetition that is required for habit
needed varies across types of habits, and (c) there are formation. Lally et al. (2010) reported that missing
individual differences in the time it takes to form a one opportunity for repetition did not affect habit for-
habit. Regarding the importance of repetition for habit mation. However, Gardner and Lally (2018) suggested
formation, Kaushal et al. (2017) allocated 94 new gym that inconsistent performance may nonetheless hinder
goers to a habit-formation group versus a control group. habit formation because “failing to act reduces the
By 8 weeks, the members of the habit-formation group likelihood of subsequent performance, derailing main-
were 1.67 times more likely to engage in moderate to tenance” (p. 215).
vigorous exercise measured with an accelerometer and Within an EBPT there are typically multiple, multistep
self-report, and they engaged in exercise with more habit-formation and habit-disruption targets, and these
consistency (i.e., more repetition), than the control targets are arguably more complex than the discrete hab-
group. This study is unique because it included a mea- its typically studied. Hence, there is a need to study how
sure of the extent of repetition of gym attendance the process of habit formation unfolds while simultane-
across the habit-formation process. Finally, Van der ously building and disrupting multiple complex habits.
Weiden et al. (2020) recruited people who wanted to Relatedly, habits are often studied in relation to actions
form a new habit in one of four domains: health, rela- performed at least once per day. Yet in EBPTs we often
tionships, spending of money, or engagement in an seek to build habits for less frequent and often intermit-
environmentally friendly practice. Over a period of 3 tent behaviors. For example, people with insomnia may
months, there was an increase in habit strength as mea- experience a poor night of sleep intermittently (e.g., four
sured by the SHRI, and the effect was strongest for nights per week). Hence, in treatments designed to
those who consistently performed the behavior. improve sleep, the skills that promote coping the day after
Regarding differences in the amount of repetition a poor night of sleep—such as the energy-generating
needed across habits and individuals, Kaushal and behavioral experiment (Harvey & Buysse, 2017)—are
Rhodes (2015) studied the process of developing the needed only intermittently. Will it therefore be harder for
habit of using a new gym membership over 12 weeks. these daytime coping skills to become habits? Gardner
A minimum of 6 weeks was required to form the habit. and Lally (2018), citing the example of weekly recycling
Fournier, d’Arripe-Longueville, and Radel (2017) moni- (Klöckner & Oppedal, 2011), suggested that habit forma-
tored the process of building physical-activity habits tion requires consistent, but not necessarily frequent,
Habit Formation and Mental Illness 579

action as long as other components of habit formation An essential point is that, in the context of EBPTs,
(discussed below) are in place. we do not know the “dose” of repetition—in terms of
EBPTs typically strongly encourage home practice the number of days/weeks—that is needed for the for-
of the topics covered within each treatment session. mation of new habits and the disruption of unwanted
This often takes the form of practicing a new skill. An habits. The dose may be higher than indicated in prior
implicit goal of home practice is to develop new habits research given that certain habits in EBPTs are not
or disrupt unwanted habits via repeated experiences. practiced every day. This will be a challenging research
However, given the importance of repetition for habit endeavor because of the number of EBPTs and because
formation and the time course for the development of each EBPT tackles multiple complex habits.
habits, it seems unlikely that a week or two of home One important aspect of repetition is to ensure the
practice will actually result in the formation of a new patient develops skills in knowing when and how to
habit or the disruption of an unwanted habit. This idea modify the habit. For example, as part of the “energy-
might, at least partially, account for the partial or full generating” intervention within some sleep treatments
relapse often observed after the completion of an EBPT. (Harvey & Buysse, 2017), a patient may plan to develop
To illustrate this point more fully, a goal of CBT-I is a habit of walking in a local park every day instead of
to develop a habit of engaging in a wind-down routine napping. However, what if after 3 weeks the patient
before bedtime during which the lights are dimmed develops an injury from daily walking (e.g., plantar
and electronics are turned off at a regular time each fasciitis)? Consider one scenario in which the course of
night of the week. The process of collaboratively devis- the treatment has finished and the patient has neither
ing the individualized wind-down might take about the knowledge nor skills to modify the habit of walking
half of a 50-min treatment session. The setup includes daily so that the injury can heal. In this case, repetition
providing a rationale and information about the envi- would cease, and the process of habit formation would
ronmental influences acting on the circadian system be adversely affected. Hence, providers should prepare
(e.g., light) and the benefits of establishing a consistent patients by providing a strong rationale, including how
wind-down and bedtime routine. The wind-down is to wisely modify the plan, so that repetition and habit
then collaboratively devised with a focus on activities formation can continue.
that the patient would enjoy and (hopefully) be intrin- RFCBT (Watkins, 2018) incorporates implementation
sically motivated to try. The homework for the coming intentions to promote repetition (Gollwitzer, 1999).
week involves practicing the wind-down, and a portion Implementation intentions are simple and quick tech-
of the subsequent session, typically 1 week later, would niques that take advantage of mental imagery and pre-
be used to review the homework and solve any prob- deciding how to implement one’s goals. This approach
lems or obstacles that were encountered when trying can be harnessed to build new habits by helping to
to implement the wind-down. In one scenario, the move goals into action (Verhoeven & de Wit, 2018) and
provider might assume that the wind-down habit has to promote repetition, particularly for less frequent or
been developed after 1 week, and the treatment would intermittent behaviors. The general format of an imple-
move on to other topics. However, given the studies mentation intention is that, after identifying a habit they
reviewed above indicating that the amount of repeti- would like to form, patients make an “if/then” plan
tion required is between 18 days to 36 weeks for rela- structured as follows:
tively discrete behaviors, a mere 7 days of practice
seems entirely insufficient for developing a habit of “If/When I encounter {situation},
engaging in a nightly wind-down. In an alternate sce- I intend to {action} at
nario, the wind-down would become a “rolling inter- {time}in {place}.”
vention” that is discussed weekly. Eventually, probably
guided by clinical intuition, the provider would assume Patients are then asked to write down this commit-
that the habit has been developed and would cease ment, visualize it as vividly as possible, and then repeat
weekly monitoring of the wind-down. Although this is this process a few times. It is thought that the mental
a somewhat better approach, there is an opportunity representation established with this procedure becomes
to reduce reliance on clinical intuition by adding a “highly activated and thus more easily accessible”
measure of habit formation, such as the SRHI or the (Gollwitzer, 1999, p. 495). In a meta-analysis of pub-
SRBAI, as part of progress monitoring. Moreover, if the lished findings from 94 articles, implementation inten-
habit has not been formed by the end of the course tions had a positive effect on goal attainment of
of treatment, then collaboratively developing a plan to medium-to-large magnitude (Gollwitzer & Sheeran,
encourage repetition after the final session will be 2006). Since this meta-analysis, there have been many
essential. demonstrations of the usefulness of implementation
580 Harvey et al.

intentions, including with people who experience men- free to devote our attention and energy to more critical
tal-health problems (Toli et al., 2016). However, it is aspects of our lives.
important to note that other studies have raised con- Automaticity is widely understood to comprise one
cerns, including that the longer term impact of imple- or more of these four features (Bargh, 1994; Verplanken
mentation intentions on habit formation is less clear & Orbell, 2003): efficiency, because few or no atten-
(e.g., Turton et al., 2016). Implementation intentions to tional resources are needed to engage in the habit;
perform alternative behaviors in response to cues asso- nonintentionality, such that our goals may not override
ciated with unwanted habits may also be more helpful engagement in the habit; lack of conscious awareness,
for weak or not-yet-developed habits compared with such that we reach for the next piece of chocolate
strong, well-established habits (Webb et al., 2009). without thinking about it; and initiation outside of voli-
EBPTs could also incorporate reminders to engage tional control.
in repetition. Tobias (2009) highlighted a critical role We also need to consider that habits involve not only
for memory and proposed the use of reminders, sent automatic responding on the perception of contextual
at a critical moment, to perform the behavior. Remind- cues but also automatic attentional biases toward con-
ers have the potential to support the habit-formation textual cues that trigger the habit (Carden & Wood,
process. Reminders to engage in repetition could take 2018). This process, of course, makes it difficult to
many forms. They might be delivered via phone, text, disrupt unwanted habits. However, as we make evident
email, or perhaps sticky notes left in an obvious loca- later, it may be possible to inhibit the habitual response
tion. Although reminders were helpful in prompting once a contextual cue has activated the habit (W. Wood
initial repetition and habit formation, their salience & Neal, 2007; W. Wood & Rünger, 2016) or substitute
diminished over time, along with their effectiveness the automatic habitual response with a new response.
(Tobias, 2009). Indeed, Carden and Wood (2018) raised Within the context of EBPTs, there is an interesting
the possibility that reminders may be effective in the opportunity to study and apply the concept of automa-
short term but may inhibit habit formation in the longer ticity. Indeed, the empirical evaluation of the process
term because reminders engage deliberate decision- of developing automaticity for specific components
making, which may impair learning. Reminders deliv- of EBPTs is rarely studied. For example, negative
ered via text or mobile app may also promote app automatic-thought forms are commonly included as
dependence, leading to a behavior that relies on the part of CBT (A. T. Beck, 1979; J. S. Beck, 2005). These
app rather than an appropriate contextual cue (Carden forms help patients learn how to become aware of their
& Wood, 2018). Future research, in the context of negative automatic thoughts or “hot thoughts.” Then,
EBPTs, is needed to determine the types of reminders guided by a series of questions, patients learn to evalu-
that are effective and to establish the time frame over ate their thoughts. Examples of common negative auto-
which they are effective. The schedule for the remind- matic thoughts are “I am useless,” “I can’t cope,” or
ers or working out if there is a “critical moment” in “They don’t like me.” The evaluation include questions
which to deliver the reminder is also another domain such as “What’s the evidence for the thought?” “What’s
for future research. the evidence against the thought?” and “What effect
does thinking this thought have on me?” Anecdotal
evidence suggests that with close to daily practice over
Habits are automatic
several weeks, negative automatic-thinking habits can
Automaticity arises as a consequence of repeating a be fundamentally changed, and patients can begin to
desired behavior in response to a stable contextual ask themselves the evaluation questions automatically.
cue (Fig. 1). It is present when a habit is performed This transition to automaticity is highly clinically rele-
with minimal effort or deliberation (Bargh, 1994; vant and has not, to the best of our knowledge, been
Bouton et al., 2011; Verplanken & Orbell, 2003; Walker subject to empirical investigation.
et al., 2015; W. Wood & Rünger, 2016). Although the EBPTs cannot rely solely on attempts to disrupt poor
centrality of automaticity to habit formation has health habits via psychoeducation and persuasive
attracted debate (Trafimow, 2018), habits are typically appeals (Marteau et al., 2012). Indeed, a meta-analysis
conceptualized as an “integration of sequences of by Webb and Sheeran (2006) reported that persuasion
responses that are automatically executed as a unit” consistently yielded a medium-to-large effect-size
(W. Wood & Rünger, 2016, p. 292). That is, within change on intention but only a small-to-medium effect-
many definitions of a habit, performance without con- size change on behavior change. For example, a com-
scious oversight is a critical component. This aspect mon practice in CBT-I is to provide education on
of habits confers multiple advantages because, if our tackling unhelpful beliefs about sleep. However, greater
day-to-day routine is engaged in automatically, we are change in these habitual beliefs might be possible by
Habit Formation and Mental Illness 581

testing the unhelpful beliefs with one or a series of Within EBPTs, RFCBT includes a thoughtful imple-
behavioral experiments (Ree & Harvey, 2004). Behav- mentation of behavior substitution. The alternative
ioral experiments are “planned experiential activities, behaviors developed as substitutes for rumination
based on experimentation or observation, which are include thinking in a more concrete and specific man-
undertaken by patients in or between . . . therapy ses- ner (Watkins et al., 2009, 2012) and guided imagery to
sions” (Bennett-Levy et al., 2004, p. 8). Because behav- re-create states of mind that are inconsistent with rumi-
ioral experiments are multisensory experiential nation (e.g., “flow” states). Great care is taken to select
exercises, they are thought to be processed at a deeper a substitute behavior that has already been used by the
level than verbal methods such as education or Socratic patient and is likely to be helpful and reinforcing. In
questioning (Bennett-Levy et al., 2004), which may be other words, the substitute behavior is chosen on the
more effective in building automaticity in habit forma- basis of its likelihood of successfully becoming instanti-
tion and reducing automaticity in habit disruption. ated as a new habit. After selecting a substitute behav-
It will also be important to empirically establish ior, RFCBT includes multiple practice sessions in which
whether some habits are easier to automate than others. the substitute behavior is enacted in response to cues
For example, are relatively discrete and well-defined that usually trigger rumination to strengthen the more
behavioral habits (e.g., establishing a rise-up routine) helpful response.
easier to establish than more complex changes to Habit reversal (Azrin & Nunn, 1973), developed for
thought (e.g., rumination) and attention (e.g., attention tics and other nervous habits, also involves behavior
bias to threat) patterns? substitution. Specifically, “competing response practice”
Functional analysis and self-monitoring are likely to involves learning a response that is incompatible with
be useful in “unpacking” the automatic process of the habit. The competing response is then enacted for
engaging in an unwanted habit. Such processes would an extended period of time after each occurrence of
involve identifying contextual cues that trigger the unwanted habit. For example, after each occurrence
unwanted habits and that increase awareness of when of a tic, patients practice engaging in the competing
contextual cues are occurring. Increased awareness of response for 3 min (e.g., strengthening opposing
cues that automatically trigger habits is a critical first muscles).
step to tackling them. Habit reversal includes explicit Anshel et al.’s values-based approach may be helpful
awareness training, during which patients are taught to in guiding patients to select substitute behaviors (Anshel
identify early warning signals and the environments et al., 2010; Anshel & Kang, 2007). This approach
associated with unwanted habits (Azrin & Nunn, 1973). involves collaboratively determining how the patient’s
Ladouceur (1979) conducted a component analysis of values compare with the costs and long-term conse-
habit reversal and found, interestingly, that awareness quences of the unwanted habits and clearly articulating
training alone is an effective intervention. the disconnect. Patients are then guided to conceptual-
A second path to addressing the automaticity of ize and select substitute behaviors that are more con-
unwanted habits is to block the enactment of the habit sistent with their values.
(Gardner et al., 2019). Indeed, substituting a new Implementation intentions can also be used to help
response to the same cue as an unwanted habit is a consumers of EBPTs break unwanted habits. Specifi-
common solution discussed in the literature (Hertel, cally, “counter habitual implementation intentions”
2004; Watkins et al., 2018; W. Wood & Neal, 2007). involve substitution. In one study, participants engaged
Moreover, “behavior substitution” is included in the in implementation intentions in which they replaced
behavior-change taxonomy, a classification system that one snack or drink with an alternative healthier snack
was developed to provide a common vocabulary for or drink (Adriaanse et al., 2011). The structure of this
evidence-based behavior-change techniques (Michie implementation intention was as follows: “If I am at
et al., 2011, 2013). Gardner and Lally (2018) also noted home/in a bar and I want a snack/drink then I will take
that unhelpful habits provide a strong cue that may [alternative].” The proposed mechanism is that a new
even promote learning of a desired new substitute response is built on encountering the cue to the
habit. However, there is reason to be cautious. Patey et unwanted habit, thus creating an association that
al. (2018) noted that studies that use behavior substitu- directly competes with the unwanted habit (Adriaanse
tion typically do not offer a theoretical rationale for the & Verhoeven, 2018). Note that “negation implementa-
substitution strategy or behaviors selected as substi- tion intentions,” which take the form of “if [situation,
tutes. Hence, going forward we will need to improve e.g., feeling bored], then don’t [habit, e.g., eat choco-
our conceptualization of behavioral substitutions to late],” appear to result in cognitive and behavioral
address why a specific substitution was selected and rebound effects (Adriaanse et al., 2011). However,
how it will disrupt the unwanted habit. “ignoring the critical cue” in the form of “if [situation,
582 Harvey et al.

e.g., feeling bored while working], then ignore [habit, automatically trigger a decision-making process that, in
e.g., the urge to snack]” does appear to help reduce the turn, may result in engagement in the desired action
performance of the unwanted habit (Adriaanse & (Maddux, 1997). These realities need to be taken into
Verhoeven, 2018). account for future measures of automaticity to be used
In the context of this section on automaticity, when within EBPTs.
new preferred habits are substituted to replace nonpre- Fourth, the SRHI is worded to index the formation
ferred habits, there is evidence that the nonpreferred of habits relating to behavior. For use within EBPTs, a
habits continue to be readily accessible (Bouton et al., measure is needed that also encompasses the formation
2011; Walker et al., 2015). In EBPTs, it will be important of cognitive (e.g., attentional bias to threat, worry) and
to determine the extent to which unwanted and pre- emotional (e.g., use of new emotion-regulation skills)
ferred new habits compete and to delineate the condi- habits. Hence, wording changes to incorporate this
tions under which preferred habits “win.” Providing broader range of goals are needed.
knowledge and skills to patients to promote stronger
automatic connections to the preferred habits will obvi-
Reinforcers promote habits
ously be key (Brewin, 2006).
The measurement of automaticity, particularly in the Thorndike’s law of effect (1927) states that if a behavior
context of EBPTs, requires further research. Recall that produces a reinforcing outcome then that behavior will
the SRBAI comprises four automaticity response items strengthen. Since Thorndike’s initial conceptualization,
to the stem “Behavior X is something . . . ”: “I do auto- a long and rich tradition of animal and human research
matically,” “I do without having to consciously remem- shows that reinforcers have a profound impact on the
ber,” “I do without thinking,” and “I start doing before frequency and longevity of a behavior (Ferster &
I realize I’m doing it.” There is a need to adapt or Skinner, 1957; Lerner, 2020). Thus, careful analysis and
further develop the SRBAI for EBPTs for several strategic use of reinforcers will facilitate habit formation
reasons. by reinforcing the repetition of the new habit in a stable
First, EBPTs typically involve working on the forma- context (Fig. 1).
tion of multiple new habits. Because progress on the A critical element to consider is the schedule for
formation of each habit may be uneven, there is a need delivering reinforcers. Continuous reinforcement sched-
to administer the SRBAI for each specific habit (e.g., one ules occur when a reinforcer follows a specific behavior
for the completion of a negative automatic-thoughts form after every instance of the behavior. In contrast, partial
each day and another for participating in a wind-down reinforcement schedules occur when a reinforcer fol-
routine each evening). Administering the SRBAI in such lows a specific behavior after only some instances of
a manner would place excessive burden on patients. the behavior. A particularly robust finding is that behav-
Second, the SRBAI is offered as a measure of auto- iors are more resilient to extinction under partial rein-
maticity. However, the extent to which it measures the forcement schedules than continuous reinforcement
formation of automaticity as well as the disruption of schedules. This is known as the partial reinforcement
automaticity—both of which are common goals of extinction effect (Capaldi, 1966; Mowrer, 1956). There
EBPTs—is not clear. are also several types of partial reinforcement schedules
Third, although the extent to which an action is that show differential effectiveness. Interval reinforce-
automatic is not dichotomous but rather falls across a ment schedules, in which reinforcers follow specific
continuum, empirically defining a cutoff on the SRBAI behaviors only after a certain time interval has elapsed,
may be helpful because it would establish a benchmark are more resistant to extinction than ratio reinforcement
(Kaushal & Rhodes, 2015; Lally et al., 2010). Relatedly, schedules, in which a behavior results in a certain prob-
for the types of habits targeted in EBPTs, it is unrealistic ability of a reinforcer (Dickinson et al., 1983; Yin &
to achieve a perfect score for an item such as “I start Knowlton, 2006). A combination of reinforcement
doing [the desired habit] before I realize I’m doing it.” schedules may be most desirable. For example, starting
For example, consider the process of building the habit with continuous reinforcement rapidly establishes a
of getting out of bed if you cannot sleep for 15 to 20 causal relationship between behaviors and reinforcers,
min, which is part of stimulus control for insomnia. and then switching to partial reinforcement promotes
Patients are unlikely to ever get to the point at which resistance to extinction (Boyagian & Nation, 1981;
they start doing this before they realize they are doing Nation et al., 1979; Nation & Massad, 1978; Nation &
it. Instead, they are likely to think “I’m awake” and then Woods, 1980).
think “I guess it’s been 15 to 20 minutes, I should get Of course, once a habit is formed, it is relatively
up” and then “I don’t want to get up” and then “but I automatically triggered by the specific context. By this
should get up.” More realistically, a cue may come to point, reinforcement is not so relevant.
Habit Formation and Mental Illness 583

In translating knowledge of reinforcers to EBPTs, explicitly build new associations with getting into bed
providers need to carefully consider how to use rein- at the beginning of the night and waking up in the
forcement for habits patients wish to disrupt and for morning. For many people, a negative association has
habits patients wish to build. been established between sleep onset with floods of
For habits patients wish to disrupt, functional analy- worry and rumination. Building new habits in which
sis will be helpful in discovering how the unwanted we reassociate the head hitting the pillow with gratitude
habitual behavior is being reinforced. For example, the practice (A. M. Wood et al., 2009) or with savoring
habit of abusing substances possibly arose initially for (McMakin et al., 2011) has the potential, over time, to
the “high” or hedonic value. However, patients may automatically evoke positive sensations and calm that
present for treatment because the high has been will facilitate sleep.
replaced with tolerance and unpleasant withdrawal. A
contrasting example is problematic technology use
Habits take time to develop
(e.g., gaming) late into the night. Connection with
friends and the thrill of competition are reinforcers and As highlighted earlier, there are a range of laboratory-
contribute to the difficulty disrupting this habit. In this based tasks that have revealed important aspects of the
case, providers could work with patients to try to obtain habit-formation process. However, because real-life
these reinforcers in nongaming parts of their life. A habits take time to develop, it is difficult to measure
harm-reduction approach (Marlatt, 1996) that shifts the and experimentally manipulate them in the laboratory.
focus from reducing gaming itself and toward reducing The best insight into the length of time it takes to
the adverse consequences of gaming may also be help- develop a habit comes from the handful of naturalistic
ful. For instance, gaming at a different time of day and longitudinal studies that we reviewed earlier. Together,
establishing the habit of turning off technology at a set these studies suggest that the time frame for habit for-
time each day would increase the opportunity of getting mation varies enormously depending on the individual
sufficient sleep during the nighttime hours. and the type of habit to be formed. For the specific and
For habits patients wish to build, there are several discrete habits that have been studied in health psychol-
considerations. Specific reinforcers may be helpful at ogy, the range was 18 days through to 36 weeks, and
the beginning of the habit-formation process to assist the pattern for habit formation is typically asymptotic.
patients in starting new behaviors. Examples include It is alarming to consider that most EBPTs fall into
praise from the therapist; between-session “cheerlead- the range of 6 to 16 sessions conducted over 6 to 16
ing” by the therapist via phone calls, texts, or email; weeks. This would be sufficient time if the goal of the
reinforcers from a parent or caregiver (e.g., sticker chart treatment is to build one discrete habit. However, EBPTs
for children); reinforcers that patients can give to them- typically seek to build and disrupt a number of complex
selves; and reinforcers that are delivered by significant habits. Given the wealth of evidence suggesting that
others (e.g., celebration dinner cooked by a friend). habits take time to develop and change, it seems highly
Providers can also optimize the habit-formation process unlikely that this is sufficient time for habits to form. If
by adopting partial instead of continuous reinforcement underfunded health systems are not likely to provide
schedules (Capaldi, 1966; Mowrer, 1956). Moreover, we more sessions for EBPTs, we need to consider how to
should consider how reinforcers may be delivered after maximize habit formation in the sessions that are avail-
the completion of a course of treatment. Reinforcers able. Shorter carefully spaced booster sessions would
could continue to support habit formation after treat- be one possibility. More generally, providers often pre-
ment has ended if the patient can self-deliver them. pare CBT patients for the time it will take to replace an
Thoughtfully spaced booster sessions with the therapist old habit with a new habit by saying, “You’ve had many
also have great potential. The appropriateness of a rein- years of practice in thinking this way, so developing
forcer may also change over time according to how these new skills will also take practice and time.”
individuals subjectively evaluate the reinforcer and their EBPTs likely intervene on complicated networks of
preferences. For example, 5 min of “freeze dancing” behaviors and multiple targets for habits to disrupt and
may initially be a highly valued reinforcer for 4-year- habits to form. Hence, it may be possible to accelerate
olds learning to stay in their own bed all night. How- progress if we develop methodology to assess and con-
ever, after three or four dance episodes, it will probably ceptualize these networks to guide treatment planning.
become clear that a new reinforcer is needed. For example, modeling approaches (Lally et al., 2010)
Finally, Marteau et al. (2012) highlighted strategies might be adapted to study bidirectional relationships
that increase positive associations with the actions we between an individual’s habits and symptoms to identify
wish to build into habits. These strategies can be which habits have the most negative influence on an
applied to EBPTs. People with sleep problems could individual’s functioning. This personalized assessment
584 Harvey et al.

of habits and related symptoms could then be targeted EBPTs would show more durability if habit-formation
in a personalized version of the appropriate EBPT principles were rigorously intertwined with treatment
(Fisher, 2015). There will be a need to determine the as usual.
optimal number of habits to intervene on and how best Table 1 offers a range of ideas for providers of EBPTs
to select them considering issues such as the habits with to incorporate the science of habit formation. Given
the greatest health impact or individual preference that the current EBPT regimen (50 min once per week)
(Spring et al., 2012). is probably not optimal for promoting the formation of
As already discussed, another pathway that may help multiple new habits and disruption of unwanted habits,
therapists effectively help patients with the multiple providers of EBPTs must ensure that patients have the
habits that are typically tackled within EBPTs may be habit-formation knowledge and skills they need to con-
to develop bundles of desired behaviors that can be tinue the process once the course of treatment has
chunked together and activated as one unit (Spring finished. Of course, this problem yields another area
et al., 2012; W. Wood & Rünger, 2016). In a similar vein, of investigation: adherence to the habit-formation pro-
Rothman et al. (2015) discussed how piggybacking cess once provider oversight is removed. How and
a new habit onto an existing habit can be helpful when to introduce new treatment content also needs
(recall the teeth-flossing example). Of course, the ever- to be considered. Providers of EBPTs often present new
important flipside is that habits patients wish to disrupt material in each session, set practice of the new mate-
will likely also take time, although this issue has been rial for homework, briefly check the homework in the
minimally studied. subsequent session, and then move on to new content.
This process is very far from harnessing the science of
habit formation. Instead, we believe that an intensive
Concluding Thoughts and and sustained focus on individual habits will be the
Recommendations fundamental building block to more successful EBPTs.
Approximately one half of patients recover and two Optimal support for habit formation is likely to include
thirds show worthwhile benefits after receiving an a longer time span over which the sessions are deliv-
EBPT in a routine practice setting (Clark, 2018). These ered, the flexibility to deliver reinforcement between
rates are highly impressive, yet there is room for sessions (e.g., through phone or other electronic con-
improvement. The central empirical question posed in tact with the patient), and booster sessions after the
this article is whether outcomes after the receipt of an main course of treatment is complete.
EBPT improve if the basic science of habit formation Finally, there are a plethora of questions and prob-
were fully leveraged. The six elements of habits dis- lems about habit formation that await probing by cur-
tilled are a first set of principles that could be infused rent and future generations of psychological scientists
into EBPTs. However, an enormous amount has yet to from a broad range of subfields. Some of these ques-
be discovered about how these processes apply to tions have been articulated here and many more are
EBPTs. This pursuit will clearly be fascinating and will yet to be defined, operationalized, and tested with the
require immense creativity in research design given creativity, precision, and rigor that characterize our
that patients typically pursue an EBPT because they field. The challenge ahead is to identify the science
wish to get help with multiple habit-formation and questions and research designs that directly illuminate
habit-disruption targets. the habits that are tackled within EBPTs.
It is noteworthy that there are at least three discern-
able patterns of the outcome from long-term follow- Transparency
ups of EBPTs: a washout of treatment effects, such that Action Editor: Laura A. King
postintervention improvements are not maintained at Editor: Laura A. King
long-term follow-up (Halldorsdottir & Ollendick, 2016; Declaration of Conflicting Interests
Rose et al., 2014); an upward spiral effect, such that A. G. Harvey has received research support from the
postintervention improvements become more pro- National Institutes of Health and book royalties from the
nounced at long-term follow-up (Compas et al., 2009; American Psychological Association, Guilford Press, and
Oxford University Press. The author(s) declared that there
Ginsburg, 2009); and an occasional delayed treatment
were no other potential conflicts of interest with respect
effect, such that improvements are evident only at to the authorship or the publication of this article.
follow-up and not immediately postintervention (Bell Funding
et al., 2013; Carroll et al., 1994). Because the most This study was funded National Institute of Mental Health
common pattern of findings is the first—at least some Grant R01-MH120147 and Eunice Kennedy Shriver National
intervention effects are lost by follow-up—another cen- Institute of Child Health and Human Development Grant
tral empirical question is whether outcomes from R21-HD097819.
Habit Formation and Mental Illness 585

ORCID iDs Psychology, 81(4), 722–736. https://doi.org/10.1037/

a0033004
Allison G. Harvey https://orcid.org/0000-0002-8609-0005
Bennett-Levy, J., Butler, G., Fennell, M. J. V., Hackmann, A.,
Catherine A. Callaway https://orcid.org/0000-0002-3065-
Mueller, M., & Westbrook, D. (2004). The Oxford handbook
6321
of behavioural experiments. Oxford University Press.
Bootzin, R. R. (1972). Stimulus control treatment for insomnia.
Acknowledgments Proceedings of the American Psychological Association,
We are grateful to Emily R. Dolsen for drafting an earlier 7, 395–396.
version of Figure 1 and for helpful discussions on habit for- Bouton, M. E., Todd, T. P., Vurbic, D., & Winterbauer, N. E.
mation. We also acknowledge the incisive comments of the (2011). Renewal after the extinction of free operant behav-
three anonymous reviewers. ior. Learning & Behavior, 39(1), 57–67.
Boyagian, L. G., & Nation, J. R. (1981). The effects of force
training and reinforcement schedules on human per-
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