The ComB Model for Trichotillomania, Explained Simply

If you’ve started looking into therapy for hair pulling, you may have come across the ComB model for trichotillomania, or the letters SCAMP, and wondered what they mean. Most explanations are written for therapists. This one is written for you.

Trichotillomania (trich) is a condition where people feel a strong urge to pull out their own hair. It affects about 1 in 50 people. This guide explains what the ComB model is, what each letter of SCAMP stands for, how ComB compares with Habit Reversal Training, what the research shows so far, and how to find someone who uses it.

What is the ComB model?

The ComB model is a way of understanding and treating hair pulling that starts with you rather than a fixed set of steps. A therapist works with you to map out what sets off your pulling and what keeps it going, then builds a plan aimed at those exact things.

The idea behind it is that no two people pull for quite the same reasons. One person pulls because a coarse hair feels wrong. Another pulls while bored at their desk. Another pulls to take the edge off feeling anxious. A plan built for one may miss the mark for the others.

The model was developed in the US by psychologist Charles Mansueto, therapist Ruth Goldfinger Golomb and their colleagues. It is a behavioural approach, which means it focuses on the patterns around pulling (what happens just before, and what pulling gives you) rather than on digging into your past. Therapists call this mapping a functional analysis: working out the job that pulling does for you.

ComB is also used for other body-focused repetitive behaviours (BFRBs). These are a group of conditions where people repeatedly pull, pick or bite at their own hair, skin or nails, such as skin picking and nail biting.

What does SCAMP stand for?

SCAMP stands for Sensory, Cognitive, Affective, Motor and Place. These are the five areas ComB looks at. For each one, your therapist asks two questions: what in this area makes pulling more likely, and what does pulling give you in this area?

Most people have drivers in more than one area. Pulling at the bathroom mirror late at night might involve all five: a stubbly hair (sensory), the thought “I’ll just even it up” (cognitive), feeling tired and wound up (affective), leaning in close to the glass (motor) and a bright mirror with tweezers nearby (place). That’s why ComB plans usually combine several small strategies rather than relying on one.

ComB covers both main styles of pulling. Automatic pulling happens without you noticing, while focused pulling is done with full awareness, often to ease an urge or a feeling. Our guide to focused and automatic pulling explains the difference.

What happens in ComB treatment?

ComB treatment moves through four phases over a series of weekly sessions. In the main research trial, that meant 12 sessions.

1. Understanding your pulling. You keep a simple record of when, where and how you pull, and your therapist asks detailed questions about each step. This is the functional analysis.
2. Choosing targets. Together you sort what you’ve learned into the five SCAMP areas and pick the drivers that matter most for you.
3. Trying strategies. You choose a few strategies for your riskiest situations, try them for a week, and report back. Anything that doesn’t help gets changed or dropped.
4. Keeping it going. The focus shifts to managing on your own, spotting early warning signs and planning for setbacks. This is called relapse prevention.

Here is an example of a plan for one situation, adapted from the model’s creators. Someone who pulls while driving to work might wear thin driving gloves (place), play calming music (sensory), breathe slowly (affective) and keep both hands on the wheel (motor). Pulling at a computer in the office would need a different set of strategies.

How is ComB different from Habit Reversal Training?

Habit Reversal Training (HRT) gives everyone the same core steps, while ComB starts from your own drivers and picks from a wider range of tools. Those tools include the main parts of HRT.

HRT was developed in the 1970s and has more research behind it than any other single therapy for BFRBs. Its core parts are awareness training (learning to notice exactly when and how you pull) and a competing response: something you do with your hands that makes pulling impossible, such as gently making fists for a minute until the urge passes. Our guide to Habit Reversal Training covers the steps in detail.

ComB’s creators argued that standard HRT didn’t deal well with the sensations, thoughts and feelings behind pulling, which may be one reason some people slipped back after treatment. Many therapists now add other methods to HRT to fill those gaps, such as acceptance and commitment therapy (ACT), which teaches you to make room for urges without acting on them. In everyday practice, the line between ComB and this wider “HRT plus” is often blurry.

Does the ComB model work?

Early research on ComB is encouraging, but there isn’t much of it yet. Here is what the studies found:

• A 2016 development study tested the first ComB treatment manual with 16 people, without a comparison group. Pulling and its impact on daily life fell by a large amount, quality of life improved, and the gains held at follow-up.
• A 2021 trial randomly split 36 adults into two groups: 12 weekly sessions of ComB straight away, or 12 weeks of waiting with brief check-ins and no treatment. People who had ComB rated their pulling as clearly better than those waiting did. Interviewers’ ratings of their symptoms didn’t differ enough to be sure of a difference. After 12 weeks, 27% of the ComB group had stopped pulling completely, compared with none of the waiting group, and gains generally held for 3 to 6 months. Results were stronger when therapists had more experience with trich.
• A follow-up published in 2022 checked in with 23 people from that trial, about two years after they started. On average, their pulling sat between where it was before treatment and where it was at their last check-in. More than half said ComB strategies were still useful.
• A 2020 study in Italy gave 8 sessions of ComB to three women. Each improved on the measures that mattered most for her own pulling, but none stopped completely.

The numbers are small, and most of the research comes from the team that developed ComB. A June 2026 review of about 30 trials found the strongest support for behavioural therapy with habit reversal and for ACT-enhanced habit reversal. It also found support for N-acetylcysteine (NAC), a supplement; always speak to a doctor or pharmacist before taking any supplement. The review noted that some promising treatments had been tested only once and need repeating, and ComB currently has one controlled trial. Because ComB includes habit reversal tools, choosing it doesn’t mean giving those up.

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

Who uses the ComB model?

Therapists trained in cognitive behavioural therapy (CBT) use ComB, especially those who work with BFRBs. CBT is a family of talking therapies that work on patterns of thoughts, feelings and behaviour. The practitioners who use ComB include psychologists, counsellors and other mental health professionals, in person and online.

The model’s creators say hundreds of therapists around the world use it. For years, formal ComB training was run by the TLC Foundation for BFRBs, a US charity that wound down at the end of 2025. Many therapists also use ComB ideas, such as matching strategies to sensory triggers, without using the name.

ComB has been adapted for children and teenagers, including in a book for parents by Ruth Goldfinger Golomb and Sherrie Vavrichek. The research trials so far have been in adults. If you’re a parent, The Parent’s Guide to Trichotillomania can help with understanding what your child is going through.

Can I use the ComB model on my own?

Yes, you can use the ideas on your own. Track your pulling for a week, noting where you were, what you were doing, how you felt and what you noticed just before. Sort what you find into the five SCAMP areas, pick your riskiest situation, and choose one strategy for each area that shows up there. Review after a week, keep what helped and swap what didn’t.

The model’s creators have also written a self-help version, Overcoming Body-Focused Repetitive Behaviors, which walks you through the same steps. For practical strategies you can start today, see our guide to how to stop pulling your hair. You can also read about every type of talking therapy in the therapy section of our complete guide.

If you’ve tried for a few months without much change, a practitioner can spot patterns that are hard to see from the inside.

When should I get help?

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

Many therapists have never worked with someone who pulls. 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. If you’d like ComB in particular, ask on a first call which approach they use and how they would adapt it to you.

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

In an emergency, call 111 or go to your nearest emergency department.

• Need to Talk? (free call or text) — 1737 (1737.org.nz)
• Lifeline Aotearoa — 0800 543 354
• Youthline — 0800 376 633

Questions people ask

Sources

1. Mansueto, C.S., Stemberger, R.M.T., Thomas, A.M. & Golomb, R.G. (1997). Trichotillomania: A comprehensive behavioral model. Clinical Psychology Review, 17(5), 567–577.
2. Mansueto, C.S., Golomb, R.G., Thomas, A.M. & Stemberger, R.M.T. (1999). A comprehensive model for behavioral treatment of trichotillomania. Cognitive and Behavioral Practice, 6(1), 23–43.
3. Mansueto, C.S. & Golomb, R.G. Comprehensive Behavioral (ComB) Treatment for Skin Picking and Hair Pulling Disorders. International OCD Foundation (updated 2025).
4. Falkenstein, M.J., Mouton-Odum, S., Mansueto, C.S., Golomb, R.G. & Haaga, D.A.F. (2016). Comprehensive behavioral treatment of trichotillomania: A treatment development study. Behavior Modification, 40(3), 414–438.
5. Carlson, E.J., Malloy, E.J., Brauer, L., Golomb, R.G., Grant, J.E., Mansueto, C.S. & Haaga, D.A.F. (2021). Comprehensive Behavioral (ComB) Treatment of Trichotillomania: A Randomized Clinical Trial. Behavior Therapy, 52(6), 1543–1557.
6. Flannery, M.K., Coyne, A.F., Carlson, E.J. & Haaga, D.A.F. (2022). Extended follow-up of a comprehensive behavioral (ComB) treatment sample during the COVID-19 pandemic. Journal of Obsessive-Compulsive and Related Disorders, 32, 100706.
7. Bottesi, G., Ouimet, A.J., Cerea, S., Granziol, U., Carraro, E., Sica, C. & Ghisi, M. (2020). Comprehensive Behavioral Therapy of Trichotillomania: A Multiple-Baseline Single-Case Experimental Design. Frontiers in Psychology, 11, 1210.
8. Fisak, B., Shorb, C., Patel, D. & Ezcurra, V. (2026). The efficacy of psychotherapeutic and pharmacological interventions for trichotillomania: A review and meta-analysis. Journal of Psychiatric Research, 197, 264–274.
9. Mansueto, C.S., Vavrichek, S.M. & Golomb, R.G. (2020). Overcoming Body-Focused Repetitive Behaviors: A Comprehensive Behavioral Treatment for Hair Pulling and Skin Picking. New Harbinger Publications.