Trichotillomania: An ACT-Enhanced Behavior Therapy Approach (Second Edition): Therapist Guide

The Trichotillomania: An ACT-Enhanced Behavior Therapy Approach therapist guide provides step-by-step instructions and evidence-based strategies for supporting individuals with trichotillomania. A client workbook is downloadable separately.

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Introduction – Introductory Information for Therapists and Assessment

Chapter 1 – Session 1: Trichotillomania (TTM) Education, Therapy Overview, Expectations, and Assessment of Pulling Triggers

Chapter 2 – Session 2: Habit Reversal Training (HRT) and Trigger Reduction Strategies

Chapter 3 – Session 3: Increasing Motivation for Treatment Through Values

Chapter 4 – Session 4: Can Pulling-Related Inner Experiences Be Controlled?

Chapter 5 – Session 5: Acceptance of Pulling-Related Inner Experiences

Chapter 6 – Sessions 6 and 7: Defusion from Your Inner Experiences: You Are Not Your Urges to Pull

Chapter 7 – Session 8: Practicing Acceptance and Commitment Therapy (ACT)

Chapter 8 – Session 9: Practicing Acceptance and Commitment Therapy (ACT) and Review of Treatment

Chapter 9 – Session 10: Review and Relapse Prevention

Chapter 10 – Modifications for Working with Adolescents

Appendices

References

Front Matter

Overview

Trichotillomania (TTM) is a condition marked by repetitive hair-pulling that leads to visible hair loss, distress, and impaired daily functioning. Often misunderstood and underdiagnosed, TTM can affect emotional well-being and lead to social and physical difficulties. This treatment manual presents a structured approach using habit reversal training (HRT) and acceptance and commitment therapy (ACT). HRT helps clients recognize and interrupt pulling with alternative behaviors, while ACT addresses urges, stress, and inflexible thinking. The program builds skills in self-monitoring and values-based action to reduce pulling and improve life quality. Spanning ten sessions, it includes psychoeducation, trigger management, acceptance of urges, and relapse prevention. Research shows it reduces pulling severity and leads to meaningful clinical improvement in individual and group settings. Designed for therapists with behavioral training, this evidence-based guide offers a practical and flexible framework for effectively treating TTM.

Why Use This Resource?

This program provides a step-by-step, structured approach for treating trichotillomania (TTM). It includes:

  • Detailed explanations of ACT and habit reversal principles tailored to TTM.
  • Effective interventions for overcoming TTM.
  • Practical guidance for structuring sessions and implementing client exercises.
  • Strategies for overcoming common obstacles during treatment.

Key Benefits

Structured

Offers a clear, session-by-session outline for delivering effective therapy.

Educational

Helps clients understand the nature of their difficulties.

Effective

Supports therapists in implementing effective interventions for addressing TTM.

Trusted

Part of the Treatments That Work™ series, developed by leading experts.

Who is this for?

Trichotillomania (TTM; Hair-Pulling Disorder)

Persistent hair-pulling leading to noticeable hair loss and distress.

Integrating it into your practice

01

Assessment

Explore how clients experience trichotillomania (TTM).

02

Psychoeducation

Teach clients about TTM and what maintains it.

03

Skills

Implement effective interventions to address TTM, drawing on ACT and habit reversal.

04

Monitoring

Use structured worksheets to track progress and refine interventions.

05

Relapse Prevention

Equip clients with long-term strategies for maintaining their progress.

Theoretical Background & Therapist Guidance

Trichotillomania (TTM), also known as hair-pulling disorder, is a chronic condition characterized by repetitive hair-pulling that leads to noticeable hair loss, functional impairment, and significant emotional distress (American Psychiatric Association, 2013). While historically under-recognized, recent research indicates a current prevalence rate of approximately 1.7% in the general population (Grant et al., 2020). TTM most commonly begins in late childhood or early adolescence, with an average onset between ages 10 and 13, and it often follows a chronic, waxing-and-waning course (Grant & Chamberlain, 2016; Stein et al., 1999). The disorder affects individuals physically, socially, and psychologically. Along with hair loss, common physical complications include scalp irritation, follicle damage, and, in extreme cases, trichobezoars, which can lead to gastrointestinal obstructions caused by hair requiring surgical intervention (Snorrason et al., 2021). Socially, individuals with TTM frequently report avoidance of public activities, interpersonal difficulties, and occupational impairment (Woods et al., 2006). Psychiatric comorbidities such as depression, anxiety, and substance use disorders are prevalent, affecting up to 80% of individuals with TTM (Houghton et al., 2016a).

This treatment manual integrates two empirically supported approaches: habit reversal training (HRT) and acceptance and commitment therapy (ACT). HRT focuses on disrupting automatic pulling behaviors by increasing awareness of triggers and implementing alternative, competing responses. ACT complements this by targeting the cognitive and emotional processes underlying focused pulling. Rather than attempting to suppress urges or uncomfortable emotions, ACT teaches clients to accept these internal experiences while committing to behaviors aligned with their personal values. This dual approach recognizes that TTM often involves both automatic and intentional pulling processes and provides targeted interventions for each (Grant et al., 2007; Flessner et al., 2008b). Research indicates that these approaches significantly reduce hair-pulling behaviors and severity, with most participants maintaining gains after treatment. Research also supports their adaptability, with group formats achieving high response rates and teletherapy yielding comparable outcomes to in-person sessions.

The program includes two books:

  • Trichotillomania: An ACT-Enhanced Behavior Therapy Approach (Second Edition): Therapist Guide
  • Trichotillomania: An ACT-Enhanced Behavior Therapy Approach (Second Edition): Workbook

Authored by leading psychologists including David Barlow, Michelle Craske and Edna Foa, Treatments That Work™ is a series of manuals and workbooks based on the principles of cognitive behavioral therapy (CBT). Each pair of books (Therapist/Clinician Guide and Workbook) - contains step-by-step procedures for delivering evidence-based psychological interventions and will help you to provide the best possible care for your clients.

At Psychology Tools, we are proud to make many of the Treatments That Work™ titles available to our members. Each book is available to download chapter-by-chapter, and Psychology Tools members with a currently active subscription to our ‘Complete’ plan are licensed to share copies with their clients.

What's inside

  • A structured, session-by-session treatment manual.
  • Therapist checklists and progress monitoring tools.
  • Detailed guidance for implementing cognitive-behavioral interventions for TTM.
  • Case examples and troubleshooting tips for common challenges.
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FAQs

No, this resource is designed for therapists. Clients may benefit from the companion Client Workbook, which provides exercises for independent practice.
The full program is designed to be completed over multiple sessions, but can be tailored to individual client needs.
The guide includes structured assessments and self-monitoring tools to evaluate symptom changes over time.
Encourage gradual implementation and support clients in identifying and addressing the barriers they encounter.

How This Resource Improves Clinical Outcomes

By integrating this resource into therapy, therapists are able to:

  • Deliver a structured, comprehensive treatment specifically developed for TTM.
  • Implement effective, evidence-based interventions.
  • Help clients maintain long-term gains through relapse prevention strategies.
  • Tailor treatment to meet diverse client needs.

References And Further Reading

  • Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869-878.
  • Barlow, D. H. (2010). Negative effects from psychological treatments: A perspective. American Psychologist, 65(2), 13-20.
  • Grant, J. E., & Chamberlain, S. R. (2016). Trichotillomania: Neurobiology and treatment. Current Psychiatry Reports, 18, 79.
  • Keuthen, N. J., et al. (2001). The Massachusetts General Hospital Hairpulling Scale. Psychiatric Research, 89, 165-179.
  • Twohig, M. P., & Woods, D. W. (2021). Acceptance and Commitment Therapy for Trichotillomania. Behavior Research and Therapy, 58, 10-23.