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Behaviour Therapy for Trichotillomania

This information is for anyone interested in knowing more about behavioural therapies to help compulsive hair-pulling. It explains what therapy involves, and how to find a therapist.

Behaviour Therapies like Cognitive Behaviour Therapy, including Habit-Reversal Therapy, and Acceptance & Commitment Therapy have been effective at relieving Trichotillomania symptoms. In studies, Behaviour Therapy fared better than common medications. Studies suggest that supportive therapies and psychoanalysis without the behaviour aspect are not effective at treating Trich.

Cognitive Behaviour Therapy (CBT) is common for treating Trichotillomania and other conditions, it takes a practical, problem-solving approach to change people's attitude and behaviour. Sometimes we base our behaviour on mistaken thoughts that we may not even be aware of. Cognitive Behaviour Therapy helps you to notice, explore and challenge false thoughts e.g. The only way this feeling will go away is with pulling, changes to: If I accept the itchy feeling and let it be, the feeling will decrease in intensity. If I continue to pull, it will only make things worse." CBT can help you address your thoughts about yourself, your relationships with others and how you relate to the world around you. CBT may also involve behaviour aspects to help you to change the way you behave, for example to reducing hair-pulling. A type of this is habit-reversal therapy; HRT is explained more below.

CBT tends to be short: an hour session a week for 3 to 6 months, with homework to complete in between, e.g. keeping records, activities or problem-solving. You work with your therapist to understand your problems and develop a strategy to apply in future life. The sessions are planned and structured, and goals are set. At the start of a session usually the client and therapist will jointly decide on the topics they want to work on that week.

Your therapist may not have treated Trichotillomania before but should be experienced in using CBT to treat a range of problems and be able to adapt the techniques to hair pulling. To be realistic CBT is not a miracle cure, you need to be open, persistent and it takes time and effort. It doesn't help everybody, it may help but not to full recovery, and for some it may take extra time practising the techniques after the course has finished.

Habit-reversal Therapy (HRT) is a CBT technique that is widely recognised as the most effective treatment for Trichotillomania. In a review of research into medications and behaviour therapies for Trichotillomania, HRT was more successful than commonly used medications. The habit-reversal therapy program for Trichotillomania consists of four main aspects.

1. Self-monitoring
2. Awareness Training
3. Stimulus Control
4. Stimulus-Response Intervention or Competing Response Intervention

Self-monitoring: Keeping a record of your hair-pulling behaviour helps you be aware of the triggers and effects of pulling. These may be a place, an action, sensory, emotions or thoughts e.g:
* A place where pulling normally occurs, like in front of a bathroom mirror
* Habits like twirling or stroking your hair when you're sitting around, often without noticing, may prompt pulling
* Sensory: enjoying the sensation of pulling or an after pulling activity like feeling the hair texture, looking at or nibbling the root
* Emotions: you may tend to pull your hair out during stressful situations and feel calmed by it, or sometimes you may feel bored before and energized/less bored after pulling
* Thoughts: "weeding out" unwanted hairs that are believed to be ugly or unacceptable

Awareness Training: Being more aware of the pulling or the urges you feel, recognising high-risk situations that often trigger pulling. Some people wear jangly bracelets to help pay attention their hands

Stimulus Control:
* Learning to avoid situations that make you pull e.g. avoid being alone by being in the same room as someone
* Using techniques to stop you from pulling e.g. change the room where you study at times when urges are strong
* Using techniques that prevent pulling e.g. wearing gloves in high-risk situations 

Stimulus-Response Intervention or Competing Response Intervention:

Stimulus-Response Intervention: Replace pulling with another action that you do every time you feel the urge to pull e.g. playing with a brush with very soft bristles, deep muscle relaxation, taking a walk

Competing response intervention:
* A barrier to prevent pulling (e.g. wearing gloves or a hat)
* Doing a physically incompatible behaviour (e.g. holding your hand open, making a fist, or flicking your fingers) for a fixed period of time (i.e., 1 minute) or until the urge goes away. In HRT, patients are permitted to pull hair only after these activities are completed.

In summary HRT involves learning about your condition, how it is treated, learning about your urges, learning not to act on your urges by carrying out a different activity instead, and creating barriers so you can’t pull.

Acceptance & Commitment Therapy (ACT) is based on the theory that hair pulling behaviour is used as a way to avoid uncomfortable feelings and thoughts. The therapy uses exercises and metaphors to accept those feelings and also helps you to move towards your goals. In a review of research into ACT, it was found to be effective for several disorders (including trichotillomania, anxiety, depression, substance abuse), although it didn’t show ACT to be any better than other established treatments. In our personal view: hair pulling triggers differ between individuals, so different therapies may work better for some than for others. If you think you might pull to avoid thinking about certain things, or in response to certain emotions, then ACT may be a good treatment for you.

How To Access Behaviour Therapies

The National Institute for Health and Clinical Excellence (NICE) recommends CBT via the NHS for depression and anxiety. Trichotillomania is often considered an anxiety disorder so you can ask your GP to refer you. Some regions offer CBT on the NHS, your GP should be able to advise you what’s available in your area. Some nurses, doctors, occupational therapists and clinical psychologists working in community mental health teams can also provide CBT. Waiting lists tend to be long and not all practitioners have good training.

There are some private practitioners, and many private hospitals employ CBT therapists. The British Association of Behavioural and Cognitive Therapy ( has a register of approved members but there is no legal requirement for therapists to register. See our Pages for Health Care Professionals  

Our online coaching program combines all these techniques as well as others from different treatments, and things that we know have worked for other people with the condition. It is tailored to what works best for you as an individual, by your personal coach who has recovered from trichotillomania.