Behavior Modification

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Acceptance-Enhanced Behavior Therapy (AEBT) for Trichotillomania

and Chronic Skin Picking : Exploring the Effects of Component
Sequencing
Christopher A. Flessner, Andrew M. Busch, Paul W. Heideman and Douglas W.
Woods
Behav Modif 2008 32: 579 originally published online 11 March 2008
DOI: 10.1177/0145445507313800

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 Behavior Modification
Volume 32 Number 5
September 2008 579-594
© 2008 Sage Publications
Acceptance-Enhanced 10.1177/0145445507313800
http://bmo.sagepub.com
Behavior Therapy (AEBT) hosted at
http://online.sagepub.com

for Trichotillomania and

Chronic Skin Picking
Exploring the Effects of
Component Sequencing
Christopher A. Flessner
Andrew M. Busch
Paul W. Heideman
Douglas W. Woods
University of Wisconsin–Milwaukee

This pilot study examined the utility of acceptance-enhanced behavior

therapy (AEBT) for trichotillomania (TTM) and chronic skin picking (CSP)
and the impact of altering treatment sequence on overall treatment efficacy.
Participants referred to a TTM and CSP specialty clinic were assessed by an
independent evaluator within separate, nonconcurrent, multiple-baseline
designs across participants. The first group of three participants received
habit-reversal training (HRT) followed by acceptance and commitment therapy
(ACT), and the second group of two participants received ACT followed by
HRT. Results indicated that AEBT greatly reduced pulling/picking for all five
participants and that the order in which ACT and HRT were implemented
made little or no difference in short-term treatment outcome. Conclusions,
limitations, and future areas of research are discussed.

Keywords: ACT; habit reversal; sequence; skin picking; acceptance

T richotillomania (TTM) is characterized by the recurrent pulling out of

one’s hair resulting in noticeable hair loss. The behavior must be
accompanied by tension prior to or while attempting to resist pulling and
by gratification, relief, or pleasure while pulling. In addition, pulling must

Authors’ Note: Direct correspondence concerning this article to Douglas W. Woods, PhD,
Department of Psychology, P.O. Box 413, Milwaukee, WI 53211; phone: (414) 229-5335; fax:
(414) 229-5219; e-mail: dwoods@uwm.edu.

579

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580 Behavior Modification

result in clinically significant distress or impairment and must not be better

accounted for by another mental health or medical condition (American
Psychiatric Association [APA], 2000). Approximately 0.6% of the population
meets diagnostic criteria for TTM (Christenson, Pyle, & Mitchell, 1991), and
the disorder is more prevalent among females (Graber & Arndt, 1993).
Although the Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR; APA, 2000) does not contain a
specific classification for chronic skin picking (CSP), the problem has been
operationally defined as recurrent picking of one’s skin accompanied by
visible tissue damage, which results in significant distress and/or functional
impairment (Bohne, Wilhelm, Keuthen, Baer, & Jenike, 2002; Keuthen
et al., 2000; Simeon et al., 1997; Teng, Woods, Twohig, & Marcks, 2002;
Wilhelm et al., 1999). Skin picking occurs in approximately 2% of derma-
tology clinic patients (Arnold, Auchenbach, & McElroy, 2001) and in 3.8%
to 4.6% of college students (Bohne et al. 2002; Keuthen et al., 2000). Like
TTM, CSP occurs more frequently in females (Bloch, Elliot, Thompson, &
Koran, 2001; Bohne et al., 2002; Simeon et al., 1997).
Although TTM and CSP are topographically dissimilar, they co-occur
quite frequently. In a survey of college students Hajcak, Franklin, Simons,
and Keuthen (2006) found that 18.1% (n = 13) of participants engaged in
both frequent hair pulling and skin picking. In addition to higher than
expected co-occurrence, those with TTM and CSP share similar demo-
graphic characteristics, psychiatric comorbidity patterns, and personality
dimensions (Cullen et al., 2001; Lochner, Simeon, Niehaus, & Stein, 2002).
Research has also suggested that both hair pulling and skin picking may
function to reduce discomfort, tension, or other negative feelings or states
(Begotka, Woods, & Wetterneck, 2004; Keuthen et al., 2000; Simeon et al.,
1997). Given these similarities, some have suggested that TTM and CSP
may be topographical variants of the same pathology and, as such, may
respond similarly to treatment (Twohig, Hayes, & Masuda, 2006; Yeh,
Taylor, Thordarson, & Corcoran, 2003).
Habit-reversal training (HRT; Azrin & Nunn, 1973) is at the center of most
behavioral treatments for TTM and CSP and involves three primary compo-
nents (i.e., awareness training, competing response training, and social sup-
port). Several single-subject and group-design studies have supported the
efficacy of HRT for the treatment of both TTM (Azrin, Nunn, & Frantz,
1980; Mouton & Stanley, 1996; Rapp, Miltenberger, Long, Elliot, & Lumley,
1998) and CSP (Kent & Drummond, 1989; Rosenbaum & Allyon, 1981;
Teng, Woods, & Twohig, 2006; Twohig & Woods, 2001). Nevertheless, large
randomized controlled trials have yet to be conducted for either disorder.

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 Flessner et al. / Acceptance-Enhanced Behavior Therapy 581

Researchers have also incorporated a number of other techniques for use

with HRT, such as stimulus control, cognitive restructuring, relaxation train-
ing, and thought stopping (Deckersbach, Wilhelm, Keuthen, Baer, & Jenike,
2002; Ninan, Rothbaum, Martsteller, Knight, & Eccard, 2000; van Minnen,
Hoogduin, Keijsers, Hellenbrand, & Hendriks, 2003). Generally, these cognitive-
behavior therapies (loosely defined as some combination of HRT and several,
if not all, of the strategies listed above) have been found to be more effective
than pharmacotherapy (clomipramine or fluoxetine, Ninan et al. and van
Minnen et al., respectively), wait-list control (van Minnen et al.), or placebo
(Ninan et al.) in treating TTM. Nevertheless, these studies have generally
utilized either single-subject designs (e.g., Deckersbach et al.), small group
sizes (5-6 participants in each group; e.g., Ninan et al.), or have failed to
collect long-term follow-up data. Because of the limited treatment outcome
literature in the area, some researchers have begun to further study TTM and
CSP phenomenology with an eye toward improving available treatments.
Most of this work has been done with TTM, although some parallels exist
within CSP (Woods, Flessner et al., 2006).
Christenson and Mackenzie (1994) first provided a description of two
styles of TTM-related hair pulling referred to as automatic and focused.
Recent evidence confirmed the existence of these two styles in persons with
TTM (Flessner, Woods, Franklin, Cashin, & Keuthen, in press) and CSP
(Walther, Flessner, Conelea, & Woods, 2007). Automatic pulling has been
defined as pulling that occurs primarily out of one’s awareness. It includes
instances in which an individual pulls while engaged in a sedentary activ-
ity, such as watching television, reading a book, or listening to the radio but
is often unaware of pulling until the episode is complete or after it has been
occurring for some time (e.g., when seeing hair on lap or clothing). In con-
trast, focused pulling has been defined as pulling with a compulsive qual-
ity, which may represent an attempt to regulate negative emotions (e.g.,
anxiety, stress, etc.; Begotka et al., 2004; Woods, Wetterneck, & Flessner,
2006) or other private experiences (e.g., urges or cognitions).
This latter style of pulling is consistent with a broader class of behavior
deemed experiential avoidance. Experiential avoidance can be described as
one’s tendency to avoid or escape negative private events or emotions (e.g.,
pulling/picking to relieve anxiety, stress, depression, etc.). Although research
supporting the relationship between experiential avoidance and TTM or CSP
is scarce, studies are beginning to appear. Begotka et al. (2004) examined a
nonreferred sample of those with TTM and found a moderate correlation
between experiential avoidance and TTM severity. Similarly, Flessner and
Woods (2006) found a moderate to strong correlation between experiential

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582 Behavior Modification

avoidance and CSP severity in 92 respondents to an Internet-based survey.

Finally, Norberg, Wetterneck, Woods, and Conelea (2007) found that experi-
ential avoidance mediated the relationships between specific cognitions and
pulling severity. Findings from these studies provide preliminary evidence
that individuals with stronger experientially avoidant repertoires tend to
demonstrate more severe symptoms of TTM and CSP.
Given the common coexistence of both focused and automatic pulling/
picking in persons with these problems (du Toit, van Kradenburg, Niehaus, &
Stein, 2001), researchers have suggested that combined treatments be devel-
oped to address both styles. Recently, Woods, Wetterneck, and Flessner (2006)
examined the efficacy of acceptance-enhanced behavior therapy (AEBT;
Twohig & Woods, 2004; Woods, Wetterneck, & Flessner, 2006) for the treat-
ment of TTM. Woods, Wetterneck, and Flessner posited that HRT would be an
effective intervention for individuals with primarily automatic pulling, but
would do little for those with primarily “focused” pulling or be only moder-
ately effective for those with both pulling styles. Recognizing that focused
pulling may be brought about as part of a larger experientially avoidant reper-
toire, and given the development of Acceptance and Commitment Therapy
(ACT; Hayes, Strosahl, & Wilson, 1999) to specifically target experientially
avoidant processes, Woods, Wetterneck, and Flessner attempted to blend the
HRT and ACT interventions. The resulting AEBT treatment package, consist-
ing of psychoeducation, ACT, and HRT, was then tested in a small randomized
controlled trial. Participants were assessed by an independent evaluator and
randomly assigned to either AEBT (n = 12) or a wait-list condition (n = 13).
After seven sessions of ACT followed by three sessions of HRT, Woods and
colleagues found significant reductions in pulling severity, frequency, and
impairment ratings for participants assigned to AEBT in comparison to those
assigned to the wait-list. Woods, Wetterneck, and Flessner also noted signifi-
cant reductions in experiential avoidance and symptoms of both anxiety and
depression, with results generally maintained at 3-month follow-up. The
authors noted that reductions in experiential avoidance predicted posttreat-
ment decreases in pulling severity.
Efficacy of AEBT for the treatment of CSP has yet to be examined.
Recently, Twohig et al. (2006) found that ACT alone reduced skin picking to
near-zero levels for four of five college students at posttreatment. Unfortunately,
treatment gains were not maintained for three of these four individuals at 3-
month follow-up, and because ACT was administered to only college students,
its efficacy for a clinical sample remains unclear. Despite these limitations,
Twohig et al. provided preliminary evidence supporting the possibly utility of
ACT for the treatment of CSP. Although not yet tested empirically, Twohig

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 Flessner et al. / Acceptance-Enhanced Behavior Therapy 583

et al. postulated that a combined treatment package, incorporating HRT, may

improve treatment outcome and possibly enhance treatment maintenance.
Acceptance-Enhanced Behavior Therapy has demonstrated preliminary
efficacy for treatment of TTM, but questions about the intervention remain.
First, AEBT has never been tested in a clinical sample of individuals with
CSP. Second, it is not clear whether presenting ACT or HRT first, produces
different end-state functioning. To begin to answer these questions, we con-
ducted a pilot study in which two versions of AEBT were implemented in
a sample with TTM and CSP. In the first version, ACT preceded HRT, and
in the second version, the order was reversed.

Methods

Prior to data collection, this study was approved by the University of

Wisconsin–Milwaukee’s (UWM’s) Institutional Review Board (IRB).

Participants
Participants (n = 6) were recruited through fliers posted at UWM (n = 1),
advertisements placed in the local newspaper (n = 2), and referrals to a
TTM and CSP specialty clinic (n = 3). Participants were included in the
current study if they (a) were 18 years of age or older, (b) did not suffer
from self-reported physical disabilities (obtained via semistructured ques-
tionnaire) or psychiatric conditions (obtained via structured clinical inter-
view), including psychotic disorders, alcohol/substance abuse, or other
serious psychiatric conditions hindering their ability to travel to and from
treatment sessions, (c) had an IQ above 80 (as measured by the Wechsler
Abbreviated Scale of Intelligence [WASI]; Wechsler, 1999), (d) had a pri-
mary diagnosis of TTM (obtained via trichotillomania diagnostic interview
[TDI]; Rothbaum & Ninan, 1994) or CSP (self-reported skin picking result-
ing in noticeable tissue damage and significant impairment/distress occur-
ring for 4 weeks or longer; obtained via the Skin Picking Inventory [SPI];
Keuthen, Wilhelm, & Deckersbach, 2000), and (e) obtained a score of 12 or
greater on the Massachusetts General Hospital–Hairpulling Scale (MGH-
HS; Keuthen et al., 1995) or the MGH-Skin Picking Scale (MGH-SPS;
Bloch et al., 2001). Participants were not excluded based on medication
status. Only one participant was on any current medication, and she did not
report a change in medication during therapy. One participant was excluded
from this study (after two sessions) because of infrequent attendance, failure
to comply with self-monitoring procedures, and indicating that she failed to

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584 Behavior Modification

Table 1
Participant’s Demographic and Phenomenological Characteristics
Participant 1 2 3 4 5

Age 23 69 6 45 36
Ethnicity Caucasian Caucasian Caucasian Caucasian Caucasian
Gender Female Female Female Female Female
Picking site Face Hands — — —
Chest
Back
Pulling site — — Scalp Eyebrows Scalp
Eyelashes Pubic
Previous treatment None None SSRIs None Risperidal
Dolls/wigs Celexa
Rubber bands Clonozapam
on wrist
Current medications — — Paxil — —
Comorbid diagnois None Somatization Dysthmia None None
disorder (r/o) Alcohol
Social dependence
phobia (r/o) (past)
Panic with
agoraphobia
Pretretreatment MGH 12 12 19 20 25
Posttreatment MGH 7 6 4 7 12

Note: SSRI = selective serotonin reuptake inhibitor; r/o = rule out; MGH = Massachusetts
General Hospital–Hairpulling Scale.

report symptoms of moderate to severe obsessive-compulsive disorder dur-

ing the pretreatment assessment. Table 1 provides descriptive data for the
remaining five participants.

Measures
Self-monitoring (Woods, Wetterneck, & Flessner, 2006). Participants were
provided with an 8.5 in by 11 in record sheet and asked to record the number
of instances of hairs pulled/skin picked throughout the day. Hair pulling was
operationally defined as “the pulling out of one’s hair via the use of finger(s)
or a device (e.g., tweezers),” whereas skin picking was operationally defined
as “the removal of one’s skin via use of finger(s) or a device.” Participants
were instructed to record the number of hairs pulled/skin picked on their
record sheet at the end of each day. Participants were asked to begin self-
monitoring following the pretreatment assessment and were asked to return
these self-monitoring sheets at the beginning of each session.

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 Flessner et al. / Acceptance-Enhanced Behavior Therapy 585

Massachusetts General Hospital–Hairpulling Scale/Skin Picking Scale

(MGH-HS/SPS; Bloch et al., 2001; Keuthen et al., 1995). The MGH scales
are 7-item self-report instruments designed to assess TTM/CSP severity over
the past week. Individual items are rated from 0 to 4 and assess severity and
resistance and control associated with hair pulling/skin picking. The MGH-
HS has shown good to very good internal consistency (σ = .80–.89; Diefenbach,
Tolin, Crocetto, Maltby, & Hannan, 2005; Keuthen et al., 1995, 2007), excel-
lent test–retest reliability (r = .97; O’Sullivan et al., 1995), and has demon-
strated convergent validity with scales of hair pulling severity (r = .63-.75;
Diefenbach et al., 2005; O’Sullivan et al., 1995) and divergent validity with
validated measures of depression and anxiety (Beck Depression and Anxiety
Inventories; O’Sullivan et al., 1995). To date, the psychometric properties of
the MGH-SPS have not been reported.

Procedures
After obtaining informed consent, participants were asked to complete
an initial screening assessment with an independent evaluator who collected
demographic information. To assess the participant’s eligibility for the cur-
rent study, several clinician-rated measures were administered including the
Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, &
Williams, 1997), WASI (Wechsler, 1999), TDI (Rothbaum & Ninan, 1994),
and SPI (Keuthen et al., 2000). Finally, participants were asked to complete
either the MGH-HS (hair pulling) or the MGH-SPS (skin picking).
A non-concurrent, multiple-baseline design across participants was
employed for the current study (Barlow & Hersen, 1984). Participants
meeting the study’s inclusion/exclusion criteria were provided with a self-
monitoring form and randomly assigned to one of two treatment conditions
(described below). Each treatment consisted of 10, 50-min sessions over
the course of 12 weeks. Sessions 1 to 8 were implemented weekly, and ses-
sions 9 and 10 were biweekly. At the start of each session, participants were
asked to return their self-monitoring form from the previous week.
Treatment sessions were conducted by master’s-level therapists (CAF,
AMB, and PH) trained in HRT procedures by the fourth author and trained
in ACT by one of the treatment’s creators (Dr. Steven Hayes). The fourth
author (DWW), a licensed clinical psychologist who is an expert in TTM
and HRT and was trained in ACT by Dr. Hayes, provided regular supervi-
sion. What follows is a brief description of the primary components to the
two treatment conditions. (Interested readers are encouraged to see Woods,
Wetterneck, & Flessner, 2006, for a more comprehensive description of the

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586 Behavior Modification

AEBT treatment.) The manuals for these two treatments are available from
the fourth author on request.
Acceptance-Enhanced Behavior Therapy with HRT Presented First
(AEBT-HRT). Acceptance-Enhanced Behavior Therapy With HRT Presented
First was a 10-session intervention incorporating several different treatment
components. Session 1 provided participants with education about TTM/CSP
and oriented the participant to the therapeutic process. During Session 2,
HRT techniques were introduced and presented as a way to reduce automatic
pulling/picking. Sessions 3 through 7 incorporated specific components of
ACT, including identification of values in one’s life and examination of how
hair pulling/skin picking has affected the individual’s ability to move toward
these values (values and uncovering the system; Session 3), examination of
attempts to control urges and other negative private experiences surrounding
one’s pulling/picking and how these control strategies have worked in the
past (creative hopelessness; Session 4), description of an alternative, non-
controlling approach to these control strategies (willingness; Session 5),
exercises designed to change the context of language supporting the fusion
of one’s private experiences as literal truths (cognitive defusion; Session 6),
and guiding the individual toward experiencing private experiences as
merely thoughts, feelings, or emotions, not as explicit definitions of who he
or she is (combining willingness and cognitive defusion; Session 7). Session
8 focused on integrating and applying ACT and HRT techniques (e.g., HRT
discussed as an intervention designed to reduce automatic pulling/picking
and an opportunity to continue practicing willingness). Session 9 provided
an opportunity to review both treatments and implement stimulus control
techniques, and Session 10 reviewed material from previous sessions and
incorporated relapse prevention strategies (e.g., periodic practice of treat-
ment strategies, application of willingness to other areas of life, etc.).
Acceptance-Enhanced Behavior Therapy with ACT Presented First
(AEBT-ACT). Although the material covered during AEBT-ACT was identi-
cal to that covered during AEBT-HRT, the sequence in which the material
was presented (except for Session 1) differed. Sessions 2 to 6 of AEBT-ACT
presented the same material as Sessions 3 to 7 of the AEBT-HRT treatment.
Session 7 focused on continued application of ACT and an introduction to
HRT, whereas Session 8 involved the implementation of HRT. During
Sessions 7 and 8, participants were reminded that HRT techniques provided
an opportunity to practice concepts learned during their previous five sessions
of ACT. Sessions 9 and 10 were identical to those in AEBT-HRT.

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 Flessner et al. / Acceptance-Enhanced Behavior Therapy 587

Results

Figure 1 displays pulling/picking frequency counts for participants ran-

domized to the AEBT-HRT condition (Participants 1, 2, and 3), whereas
Figure 2 displays pulling frequency counts for participants randomized to
the AEBT-ACT condition (Participants 4 and 5).
Overall effects of AEBT on TTM/CSP. Visual inspection suggests that
AEBT was effective for each of the study’s five participants. There appeared
to be a significant reduction in hair pulling/skin picking frequency from
pretreatment (i.e., participant’s first 7 data points; M = 188.40; SD =
102.7)1 to end of treatment (i.e., participant’s final 7 data points; M = 33.20;
SD = 31.3). The mean pre–post MGH reductions for participants with CSP
was 5.5 (SD = 0.71; 49.5% symptom reduction) and 13.67 (SD = 1.15;
65.3% symptom reduction) for those with TTM.2 As well as replicating the
efficacy of AEBT for TTM, these data are the first to suggest that AEBT
may be efficacious for CSP.
Effects of treatment sequence on end-state functioning. Findings across
the five participants suggest that independent of treatment sequence, all five
participants improved. It is also interesting to note the individual patterns
of responding, as they may suggest specific component effects. Figure 1
suggests that HRT alone, independent of its effect in combination with
ACT, was sufficient to reduce Participant 3’s pulling frequency to near-zero
levels. However, HRT alone demonstrated no discernible effect for Participants
1 or 2. Reductions in pulling/picking frequency for these participants only
occurred after ACT techniques were added. Figure 2 suggests that admin-
istration of ACT alone, independent of its effect in combination with HRT,
reduced pulling frequency to near-zero levels for Participant 5. Further
examination of results from Participant 4 revealed that ACT had little effect
on pulling frequency until combined with HRT.

Discussion

This is the first study to examine efficacy of AEBT in persons with CSP
and whether the sequence of ACT and HRT yields different end-state func-
tioning. Results support previous research suggesting that AEBT is effec-
tive for reducing pulling frequency and severity in persons diagnosed with
TTM (e.g., Twohig & Woods, 2004; Woods, Wetterneck, & Flessner, 2006)
and suggests that it is also effective for reducing picking in persons with

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588 Behavior Modification

Figure 1
Hair Pulling/Skin Picking Frequency for Participants 1 Through 3.
Acceptance-Enhanced Behavior Therapy With Habit-Reversal
Training First (AEBT-HRT)

Baseline HRT + ACT

50 ACT added
45
40
35 Participant 1
Skin Picked/Day

30 HRT/ACT
25
20
15
10
5
0

12
Skin Picked/Day

10

8 Participant 2
HRT/ACT
6

120

100
Hairs Pulled/Day

80 Participant 3
HRT/ACT
60

40

20

0
1 8 15 22 29 36 43 50 57 64 71 78 85 92 99
Days Since Pre-Tx Assessment

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 Flessner et al. / Acceptance-Enhanced Behavior Therapy 589

Figure 2
Hair Pulling Frequency for Participants 4 and 5. Acceptance-
Enhanced Behavior Therapy With Acceptance and Commitment
Therapy First (AEBT-ACT)

ACT + HRT

50
HRT added
Hairs Pulled/Day

40

30
Participant 4
20 ACT/HRT

10

120
100
Hairs Pulled/Day

80
60 Participant 5
ACT/HRT
40
20
0
1 8 15 22 29 36 43 50 57 64 71 78 85 92 99
Days Since Pre-Tx Assessment

CSP. The overall sequence of implementation did not seem to influence

efficacy, but different clients seemed to demonstrate different response pat-
terns, with some responding to either HRT or ACT alone but most receiv-
ing the greatest benefit when the components were implemented together.
One potentially valuable next step in research could be the identification
of client characteristics capable of predicting differential response to HRT
alone, ACT alone or the combination (i.e., AEBT). A logical starting point for
this work may be treatment selection based upon an assessment of automatic

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590 Behavior Modification

and focused pulling/picking. Recently, Flessner et al. (in press) and Walther
et al. (2007) developed and validated two instruments designed to assess
these pulling and picking styles, respectively. Use of these measures during a
pretreatment assessment may provide researchers and clinicians the opportu-
nity to choose a strategy given a client’s propensity for automatic or focused
pulling/picking. For example, an individual reporting primarily focused
pulling/picking (in comparison to automatic pulling) may be best-suited to
receive ACT, whereas those experiencing primarily automatic pulling/picking
may be best-suited to received HRT, and those reporting both types of
pulling/picking might be best served by a combination treatment.
Despite the clinical implications described above, the current study was
a pilot endeavor and has several notable limitations. First, use of a small
sample limits broad generalization of this study’s findings. Future research
should attempt to replicate these findings using larger samples and group
comparisons with a supportive therapy control. Second, although self-
monitoring has been used frequently in both the TTM and CSP literature
(Deckersbach et al., 2002; Teng et al., 2006; Twohig et al., 2006; Twohig &
Woods, 2004) and is compatible with the repeated measurement require-
ments of single subject experimental designs, it may be confounded by the
participant’s lack of awareness of pulling/picking, failure to accurately
record his or her pulling/picking, or other self-reporting biases. Future research
should supplement such measures with product measures (i.e., measures of
hair loss or skin damage ratings) and other psychometrically sound assess-
ment measures. Finally, although the intervention did result in a substantial
decrease in the mean levels and the variability of pulling/picking from base-
line, the highly variable baseline performance should lead one to interpret
the findings with caution.
Despite limitations described above, the current study is the first to
examine the effects of different sequences of ACT and HRT in the efficacy
of AEBT. Future research should examine the possibility that administra-
tion of HRT, ACT, or some combination may produce differential treatment
effects for participants reporting varying levels of focused and/or automatic
pulling. Similarly, studies utilizing group designs may provide beneficial
information regarding not only which treatment approach is more effica-
cious, but also whether specific participant characteristics (besides pulling
styles) predict better treatment success for these respective treatment pack-
ages. Continued research in this area will provide important information
with respect to the therapeutic interventions best-suited to treat CSP and
TTM.

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 Flessner et al. / Acceptance-Enhanced Behavior Therapy 591

Notes
1. Participant 3 failed to report hairs pulled on Day 3 of self-monitoring following her pre-
treatment assessment. As a result, Days 1 through 2 and Days 4 through 8 were summed for
this calculation.
2. Due to attrition of Participant 3 following Session 9, this session’s MGH-HS score was
substituted for Participant 3’s posttreatment MGH-HS score.

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Christopher A. Flessner is a graduate student at the University of Wisconsin–Milwaukee and

is currently completing his internship at Brown Medical School. His primary area(s) of inter-
est include the etiology, maintenance, and treatment of OCD and other OC-spectrum disor-
ders, including trichotillomania, skin picking, and tic disorders.

Andrew M. Busch is a doctoral student in clinical psychology at the University of Wisconsin–

Milwaukee. His research interests include psychotherapy process, behavioral theories of
depression, and dissemination of empirically supported treatments.

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594 Behavior Modification

Paul W. Heideman is a doctoral student in clinical psychology at the University of Wisconsin–

Milwaukee and is currently completing a predoctoral internship at the Medical University of
South Carolina. His primary research interests include substance use treatment outcome, cog-
nitive factors impacting substance use, and substance use among dental patients.

Douglas W. Woods, PhD, is an associate professor of psychology and the director of clinical
training at the University of Wisconsin–Milwaukee. His current research interests include the
assessment and treatment of tic disorders, trichotillomania, and other OCD-spectrum disorders
in children, adolescents and adults. He has published widely in these areas. He is also a
member of the Trichotillomania Learning Center’s Scientific Advisory Board and a member
of the Tourette Syndrome Association’s Medical Advisory Board.

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