Trichotillomania: An ACT-Enhanced Behavior Therapy Approach (Second Edition): Workbook
Trichotillomania: An ACT-Enhanced Behavior Therapy Approach (Second Edition) comes in two volumes. This page is for the Workbook. Click here to access the Therapist Guide.
Trichotillomania (TTM) is a condition characterized by repetitive hair-pulling that causes visible hair loss, significant distress, and impairment in daily functioning. Often misunderstood and underdiagnosed, TTM can impact emotional well-being and lead to social and physical complications. This treatment manual offers a comprehensive approach to managing TTM by combining habit reversal training (HRT) and acceptance and commitment therapy (ACT). HRT teaches clients to recognize and interrupt pulling behaviors with alternative actions, while ACT addresses the emotional and cognitive factors driving the behavior, such as urges, stress, and psychological inflexibility. The program emphasizes skill-building, self-monitoring, and values-based action to reduce pulling and improve quality of life. Structured across ten sessions, it includes psychoeducation, trigger reduction strategies, acceptance of pulling-related experiences, and relapse prevention techniques. Research supports the efficacy of this approach, showing significant reductions in pulling severity and meaningful clinical responses in both individual and group formats. Designed for therapists with experience in behavior therapy, this evidence-based guide provides a flexible and effective framework for treating TTM.
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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
Weekly Graph of Progress
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Introduction & Theoretical Background
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
Therapist Guidance
Each Treatments That Work® title is published in multiple volumes:
- Clients use the Workbooks, which contain elements of psychoeducation, skills development, self-assessment quizzes, homework exercises, and record forms.
- Therapists use the Therapist Guides, which contain step-by-step instructions for teaching clients’ skills, overcoming common difficulties.
Although written for the client, the exercises in the Workbook are intended to be carried out under the supervision of a mental health professional. The authors suggest that the most effective implementation of these exercises requires an understanding of the principles underlying the different procedures, and that mental health professionals should be familiar with the Trichotillomania: An ACT-Enhanced Behavior Therapy Approach (Second Edition): Therapist Guide as well as this Workbook
Therapists with an active subscription to a Psychology Tools ‘Complete’ plan are licensed to use Treatments That Work® titles, and to download and share chapters with their clients.
References And Further Reading
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Press.
- Asplund, M., Ruck, C., Lenhard, F., Gunnarrson, T., Bellander, M., Delby, H., & Ivanov, V. Z. (2021). ACT-enhanced group behavior therapy for trichotillomania and skin-picking disorder: A feasibility study. Journal of Clinical Psychology, 77, 1537–1555.
- Crosby, J. M., Dehlin, J. P., Mitchell, P. R., & Twohig, M. P. (2012). Acceptance and commitment therapy and habit reversal training for the treatment of trichotillomania. Cognitive and Behavioral Practice, 19, 595–605.
- Flessner, C. A., Conelea, C. A., Woods, D. W., Franklin, M. E., Keuthen, N. J., & Cashin, S. E. (2008a). Styles of pulling in trichotillomania: Exploring differences in symptoms severity, phenomenology and functional impact. Behaviour Research and Therapy, 46, 345–357.
- Flessner, C. A., Woods, D. W., Franklin, M. E., Cashin, S. E., Keuthen, N. J., & the Trichotillomania Learning Center Scientific Advisory Board. (2008b). The