ACT for Trichotillomania: How ACT and DBT Help Hair Pulling

If you’ve looked into therapy for hair pulling, you may have come across ACT and DBT. This guide explains what each is, how therapists use them with habit reversal, and what the research shows.

In short, ACT for trichotillomania (trich) is usually added to habit reversal, and that combination has strong research support. DBT is used in a similar way when pulling is closely tied to strong emotions, but it has been studied much less.

What is ACT?

ACT (acceptance and commitment therapy) is a talking therapy that helps you make room for uncomfortable thoughts, feelings and urges without letting them decide what you do. Instead of fighting an urge to pull, you notice it, let it be there, and choose what to do next.

ACT builds what its developers call psychological flexibility: staying in the present moment and acting in line with what matters to you, even when it’s uncomfortable. The main skills are:

• Acceptance: letting urges and feelings come and go, rather than struggling to get rid of them.
• Defusion: seeing a thought as just a thought. “I have to fix that hair” becomes “I’m having the thought that I have to fix that hair”, which loosens its grip.
• Being present: noticing what’s happening in your body and around you, right now, without judging it.
• Values: working out what really matters to you, such as family, work or feeling free to wear your hair how you like.
• Committed action: taking small, practical steps towards those values, again and again.

ACT fits trich because pulling often works as an escape from boredom, tension or an itchy, uneven feeling. Researchers call this pushing away of uncomfortable inner experiences “experiential avoidance”. In an early trial, people whose experiential avoidance dropped the most tended to improve the most.

What is DBT?

DBT (dialectical behaviour therapy) is a skills-based talking therapy for people who feel emotions very intensely. It was adapted from cognitive behavioural therapy (CBT), a practical therapy that works on the links between thoughts, feelings and actions. “Dialectical” means holding two things at once: accepting yourself as you are, while working to change.

The psychologist Marsha Linehan developed DBT in the 1970s, originally for borderline personality disorder. Today its skills are used much more widely. It teaches four groups of skills:

• Mindfulness: paying attention to the present moment, on purpose and without judging.
• Distress tolerance: getting through a hard moment without doing something that makes it worse.
• Emotion regulation: understanding your emotions and bringing their intensity down.
• Interpersonal effectiveness: asking for what you need and setting boundaries with other people.

Standard DBT is intensive and often lasts six months to a year. The versions tested for hair pulling were much shorter and built around habit reversal.

How are ACT and DBT used alongside Habit Reversal Training?

In trich research, ACT and DBT are usually added to Habit Reversal Training (HRT) rather than used instead of it. HRT is the behavioural therapy with the strongest research record for hair pulling. It teaches you to notice when and where you pull, to use a “competing response” (an action you can’t do while pulling, like pressing your palms flat on your thighs), and to change your surroundings so pulling is harder.

Habit reversal handles the mechanics of pulling. ACT and DBT handle what’s behind it:

• ACT helps with urges and thoughts: a way to sit with an urge instead of giving in, and a reason to keep practising (your values).
• DBT helps with feelings, especially when pulling is how you cope with stress, anger, sadness or feeling overwhelmed.

This matters because not all pulling is automatic. Many people also do focused pulling: they feel an urge or a build-up of tension, and pulling eases it. That kind of pulling often needs more than habit reversal alone. Our guide to focused and automatic pulling explains the difference.

Our guide to Habit Reversal Training explains the core steps in detail.

What does the research say about ACT for trichotillomania?

ACT combined with habit reversal has good research support, including a large trial and a 2026 review of the trials so far. ACT on its own has been tested in one small trial.

The 2022 trial stands out because it compared ACT-enhanced habit reversal with another real therapy, not just a waiting list, and the people rating progress didn’t know who had which. By six months the comparison group had caught up, but the researchers suggested the ACT-enhanced approach may suit more severe pulling best.

The 2026 review pooled 29 trials. It found strong support for three treatments: behaviour therapy with habit reversal, ACT-enhanced habit reversal, and a supplement called N-acetylcysteine (NAC). Therapies that included habit reversal did better than those without it. Most people in the largest trial were women, and none of the trials was very large.

What does the research say about DBT for hair pulling?

DBT-enhanced therapy for hair pulling looks promising, but the evidence is early. So far it comes from two small studies by one research team.

• An open trial in 2010 (one with no comparison group) gave 10 women 11 weekly sessions of habit reversal with DBT skills, then 4 maintenance sessions over 3 months. Pulling and emotion regulation both improved. Six months after the maintenance sessions ended, 5 had improved fully and 4 partly, though some scores had slipped a little.
• A controlled trial in 2012 randomly assigned 38 people to DBT-enhanced therapy or to a “minimal attention” group, who waited 11 weeks before starting treatment. The treated group improved more in both pulling and emotion regulation.

In both, people whose ability to manage emotions improved the most tended to pull less. The approach was designed for pulling triggered by emotions, and to help people keep their progress after therapy ends. It hasn’t yet been compared with another active therapy.

Does mindfulness help hair pulling?

Mindfulness is part of both ACT and DBT, and it can help you catch pulling earlier: noticing the first move of your hand, or the start of an urge, before you’re several hairs in.

On its own, it has barely been studied for trich. In a 2015 case study, one person’s hair loss improved six months after a mindfulness course without habit reversal. One person can’t tell us how well it works for others, so mindfulness is best seen as a skill that supports habit reversal, not a replacement for it.

Can ACT and DBT help children and teenagers?

Possibly, but there’s less research in young people. A 2026 review of treatment for children with trich found behavioural therapies, especially habit reversal, gave the greatest benefit. The 2020 ACT trial included teenagers, and a 2024 paper described ACT-enhanced habit reversal for young people as a new approach. We haven’t found trials of DBT for trich in children.

If you’re a parent, a practitioner who works with young people who pull can suggest what suits your child. The Parent’s Guide to Trichotillomania, understanding what your child is going through, is written for you.

Which approach might suit me?

Habit reversal is a sensible base for almost everyone. Whether you add ACT, DBT or neither depends on what drives your pulling:

For how ACT and DBT sit alongside cognitive behavioural therapy, see our guide to CBT for trichotillomania.

For every option and the evidence behind each, see our guide to trichotillomania treatment.

When should I get help?

Get support if pulling is causing you distress, taking up a lot of your time, or affecting your work, relationships or confidence. You don’t need to wait until it feels “bad enough”.

When you contact a practitioner, it’s fine to ask how they would work on the pulling itself, and whether they draw on ACT or DBT skills. Training in ACT or DBT doesn’t always mean experience with hair pulling, so ask about that too.

Everyone in our directory has told us they understand trichotillomania and already help people who pull, in person or online. You can search the directory to find someone who understands hair pulling. Our complete guide also has a short overview of each talking therapy.

If you’re feeling very low or hopeless, please talk to someone today.

In an emergency, call 911 or go to your nearest emergency department.

• 988 Suicide Crisis Helpline — 988 (988.ca)

Questions people ask

Sources

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