Behavioral Interventions for Trichotillomania

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Trichotillomania (TTM) is considered by many mental health specialists to be one of the most interesting and most difficult disorders of the OCD family. Finding the best behavioral interventions for trichotillomania is rather perplexing for both the sufferer and the practitioner trying to help the patient. One of the best treatments is Cognitive Behavioral Treatment (CBT) which is endorsed by the Trichotillomania Learning Center (TLC).

In addition to CBT, another highly endorsed treatment for hair pulling is HRT Plus which is a combination of Habit Reversal Training (HRT) and Stimulus Control (SC). A study conducted in the 1970s regarding this method found a 90% improvement for those with TTM and many behavioral specialists rely on HRT Plus as one of the most effective interventions for trichotillomania. Learn what TTM really is by reading What is Trichotillomania?

What is HRT Plus

HRT Plus is a combination of Habit Reversal Training that is a 4 step program and followed up with Stimulus Control. The four step program begins with the first step, and then each following step is introduced. In the end, the patient uses all of these steps simultaneously to help stop pulling their hair out.

This behavioral treatment program for those with TTM teaches patients ways to reverse their obsessive habit to pull out their own hair by providing them with steps to help stop the compulsion to do so.

How Does HRT Plus Work to Stop Obsessive Hair Pulling

The first step of this program involves the person to log their bouts of hair pulling. They are to list the time, where they were, how many hairs were pulled out, if they felt the urge to pull out their hair, or if they were pulling their hair without noticing until it was already in progress or over with. Behavioral specialists who use this program believe that by having the TTM patients log their hair pulling episodes, it will cause them to be more aware of the seriousness of their condition as well as give them some insight as to what may be causing them to pull their hair out. Learn some common causes of hair pulling by reading What are the Causes of Trichotillomania.

The next step involves having the patient learn muscle relaxation techniques. Generally they watch a video and learn a 15 minute exercise on how to relax their muscles. Most patients, after a couple of weeks of doing this relaxation technique a couple of times a day will soon learn to compact the exercise into 60 second exercises and get the same benefit. The trichotillomania behavioral specialist will instruct the patient to do these one minute relaxation exercises several times a day.

The third step of the program involves teaching the TTM patient breathing exercises. This can be compared to the type of breathing taught in yoga or meditation. The patient is taught to do these exercises by breathing in from their diaphragm. This diaphragmatic breathing will later help the patient to relax and breathe through an urge to pull their hair out.

The fourth step involves teaching the patient to clench their fists, bend their arm to a 90 degree angle, and hold their arms to their sides. By doing this when the urge to pull their hair begins, they will be unable to do so because their fists will be closed and their arms to their sides. This is known as a competing response. By holding their clenched fists to their side during an urge they are disallowing themselves to pull their hair. This process is also one that will not draw much attention if the person is in public when the urge to pull their hair starts.

After learning all four of these steps the behavioral interventions for trichotillomania will all be brought together and used simultaneously. When a person begins to have the urge, they will incorporate each step to avoid pulling their hair.

What is Stimulus Control for Trichotillomania Behavioral Treatment

The goal of stimulus control for patients with TTM is to make them more aware of what causes them to pull their hair out, such as stress or boredom. SC teaches patients how to identify what causes the urge and provides them with alternatives. It also teaches them how to avoid situations that cause them to pull their hair out.

Adding Stimulus Control to the Habit Reversal Treatment is the “Plus” in HRT Plus and this combination of behavioral treatment for trichotillomania makes it one of the leading effective treatments for those with a hair pulling disorder.

Many specialists believe that the success rate from using HRT Plus is much higher than using just CBT or just medication. However, the specialist do often agree that these types of behavioral interventions for trichotillomania are effective as well, but believe that HRT Plus in addition with CBT and medication will make for the best treatment. The behavioral treatment goal for those with TTM is to help people with the disorder to control their urge and to eliminate or at least reduce the hair pulling urges or hair pulling episodes. This program also has a relapse program for those who use the 4 step program and the SC treatment for when they slip up and begin pulling again. The back up plan is simply a quick re-introduction of the initial program. The patient will start the process again on their own and do the steps simultaneously. If they are unable to stop pulling their hair out with the behavioral treatment on their own at home, the specialist will suggest they re-enter the behavioral program again and the mental health specialist will incorporate more unique steps for the patient so that he or she can cure trichotillomania or at least limit the episodes and urges to pull their hair out.


Welcome to the Trichotillomania Learning Center -

Cognitive-Behavioral Treatment of Trichotillomania -

Fact Sheet: Trichotillomania -