Acceptance and Commitment Therapy for Trichotillomania (2018 study)

On researchgate you can actually download the entire article written by university of Utah researchers who did the study here in August 2018.

Question for you; How willing are you to experience the urge of pulling without doing anything but experience it?

Essentially, HRT (Habit reversal therapy) has been the “go to” method for treating trich (TTM) but it still seem to fail to address issues underlying TTM;

“However, HRT does not account for emotional and cognitive difficulties that usually occur within trichotillomania and are a major component of focused pulling (Flessner, Penzel, & Keuthen, 2010; Franklin, Zagrabbe, & Benavides, 2011; Lootens & Nelson-Gray, 2016). Further, following through with a behavioral response (in automatic or focused pulling) is challenging when faced with intense bodily sensations and thoughts about needing to pull.

One thing I enjoy is someone finally put into words that although there are two types of pulling in TTM (focused vs automatic), it appears they both exist in some degree in all individuals with TTM.

“Trials combining DBT with HRT have demonstrated reduction in trichotillomania severity with adults and adolescents (Keuthen et al., 2011; Keuthen et al., 2012; Keuthen et al., 2010; Keuthen & Sprich, 2012; Welch & Kim, 2012). For example, Keuthen et al, 2012 reported a statistically significant 42.7% decrease in hair pulling severity scores in treatment completers at post-treatment. Another trial demonstrated a statistically significant 48.6% decrease in hair pulling severity in nine treatment completers at a six-month follow-up (Keuthen et al., 2011). Additionally, trials combining ACT with HRT have shown promising results, reducing trichotillomania severity with adults and adolescents (Crosby, Dehlin, Mitchell, & Twohig, 2012; Fine et al., 2012; Twohig & Woods, 2004; Woods et al., 2006).”

So essentially making the case the HRT and DBT do help in reducing severity of TTM. Also, we do note that these are not big studies. We can also note that a 6 month follow-up may not guarantee long term progress but it’s good anyway. I’ll take it. TTM is a lot about getting back on the wagon anyway. Maybe the ride gets longer each time.

“There is mounting evidence that ACT enhanced HRT (ACT/HRT) is able to effectively target automatic and focused pulling. “ So They give some pilot studies that show reduction in severity of TTM too. What is meant by ACT enhanced, I wonder? Both DBT and ACT are suppose to target the emotional regulation in relation to hair pulling. Both seem to help in smaller studies. Small studies to me is under 30 people.

“Theoretically, ACT aims to increase psychological flexibility, which can be defined as the ability to engage in meaningful, values-directed behavior without any particular regard for inner experiences (i.e., thoughts, emotions, sensations). Psychological flexibility has been shown to be associated with lower levels of hair pulling severity, less frequent and intense urges to pull, and lower levels of distress related to pulling (Begotka, Woods, & Wetterneck, 2004; Bluett, Homan, Morrison, Levin, & Twohig, 2014; Twohig, Morrison, & Bluett, 2014).

For example, in the treatment of trichotillomania, an ACT therapist would demonstrate the futility of attempting to change or control the client’s urge to pull, instead focusing on increasing the client’s willingness to experience the urge to pull as it is. This would allow the client to better experience urges as simply bodily sensations and internal thoughts that do not need to be removed before engaging in meaningful life actions.”

“The purpose of the current study is to examine ACT alone as a treatment for trichotillomania in a randomized controlled trial of adults and adolescents. We chose to allow adolescents and adults into the study because the research question (“does ACT work without HRT?”) can be answered across age groups, and recruitment of participants with a diagnosis of trichotillomania is difficult. Moreover, the study will examine the role of psychological flexibility in treatment outcomes.

Hypothesis: “We predict that ACT alone as a treatment for trichotillomania would demonstrate significant reductions in hair pulling symptoms and psychological inflexibility compared to a waitlist control condition. We hope to gain a better understanding the contributions that ACT provides to the treatment of trichotillomania.”

Results: “The results indicate that some, but not all, adults and adolescents respond to ACT alone as a treatment for trichotillomania with adolescents demonstrating overall less improvement than adults.”

Take home? Doing ACT will likely help, and doing ACT or DBT with HRT will likely help more. To what extent, it would vary.

You might still be wondering what in the world is ACT too. I feel a little deprived of the details but;

“Contacting the present moment in ACT emphasizes awareness and openness to experiences and often includes describing thoughts, urges, and sensations without attempts to change or control them while engaging in valued behavior. This process is similar to awareness training found in HRT that attempts to bring greater attention to urges to reduce automatic pulling.”


“ACT alone and ACT/HRT appear to be quality treatments for at least a significant portion of individuals with trichotillomania. It is likely that both share some processes of change and target the major components of trichotillomania. This may also be the case for other treatments, such as DBT, that have produced similar results. Therefore, it may not matter which treatment is used, so long as the automatic and focused elements of the pulling behavior are addressed. However, this small trial is the only examination of ACT alone for trichotillomania and these results should be interpreted with caution. It appears that ACT alone is potentially comparable to ACT/HRT; however, ACT/HRT has substantially more evidence for its efficacy at this time.

The findings provide additional evidence for the utility of ACT as a component of trichotillomania treatment, especially in adults. Moreover, the findings indicate that ACT alone is a potentially viable treatment, with or without explicit HRT components. For adults it appears that the specific methods of trichotillomania treatment are less important than the processes they target, so long as the automatic and focused components of hair pulling behavior are properly addressed. “

Emily Kight