ACT-Enhanced Behavior Therapy (A-EBT) is a behavioral treatment for body-focused repetitive behaviors (BFRBs) developed by Woods and Twohig (2023). This treatment is typically 10 weekly sessions and consists of two phases: 1) Habit Reversal Training (HRT) + trigger reduction strategies and 2) Acceptance and Commitment Therapy (ACT). The total number of sessions can vary based on the individual and their response to treatment. The goals of A-EBT are to manage and reduce BFRBs and to improve quality of life and functioning impacted by BFRBs.

What is ACT-Enhanced Behavior Therapy (A-EBT)?

A-EBT starts with Habit Reversal Training + trigger reduction strategies. HRT was developed in 1973 by Azrin and Nunn (Azrin & Nunn, 1973). This is a brief behavioral treatment that consists of increasing awareness of the cues for BFRBs, adjusting the environment to reduce BFRBs, doing behaviors that interrupt BFRBs, and considering how the support from others may or may not be useful. This portion of the treatment is especially well-suited to reduce non-focused BFRBs, ones that occur outside of awareness (e.g., scrolling on the phone and picking, driving and pulling). HRT can be a very effective treatment when consistent with it. However, although the treatment is rather straightforward, it can be challenging to maintain. Thus, other treatments have been used in combination with HRT to increase its effectiveness and to incorporate thoughts, emotions, and sensations into treatment more explicitly.

One of those treatments is Acceptance and Commitment Therapy (ACT; said as one word, not Aye Cee Tee, Hayes, et al., 2011). ACT is a type of Cognitive Behavioral Therapy that is useful across many mental health experiences (Grant et al., 2020; Loureiro et al., 2026). For BFRBs, ACT is particularly useful for focused BFRBs (ones that occur with awareness and intention) and consistency with HRT. ACT helps experience urges, emotions, and thoughts differently so they have less of an effect on behavior. For example, a tingling sensation on the scalp or a thought “I’ll stop after I get this one” can still occur and be experienced with more ease while not acting on them. It can create a pause between the urge and the action, leaving space for different decisions. In ACT, values (or ways of living a rich and meaningful life) are a primary way of guiding decision making in that moment…the moment in front of the mirror, tweezers in hand, just getting that last one…it creates a pause and an opportunity to shift to something that is more meaningful…getting to work on time, spending time with loved ones, wearing shorts, and behaving confidently in your body. Making that shift from the immediate reward of continuing the BFRB to moving away from the situation toward something more meaningful requires the ability to experience strong urges and thoughts in the moment. ACT focuses on skills that help you do this.

Who can benefit from ACT-Enhanced Behavior Therapy (A-EBT)?

There are currently 17 studies that have focused on A-EBT as a treatment for BFRBs. These studies have all focused on either trichotillomania or skin picking disorder. Ten of the studies focused on treatment for trichotillomania, four focused on treatment for skin picking disorder, and three tested the treatment for people with either trichotillomania or skin picking disorder. It is important to note that in clinical practice this treatment has been used to address various BFRBs including, but not limited to trichotillomania and skin picking. Also, new research is testing A-EBT for BFRBs broadly rather than one specific BFRB.

Most of the current studies have been with adult participants although some have been with adolescents. There are no studies yet that have tested A-EBT for kids under 12 years old. Two studies tested A-EBT with adolescent participants between ages 12-18 years old. The remaining 15 studies included only adults. Across studies, participants saw their BFRB improve.

The research on A-EBT has also looked at if anxiety or depression symptoms, or other diagnoses, prevent people from seeing improvement in their BFRB. Currently, the research shows symptoms of anxiety and depression and/or having multiple diagnoses, do not prevent people from seeing their BFRB symptoms reduce. 

How effective is ACT-Enhanced Behavior Therapy (A-EBT)?

Current research supports the use of A-EBT for BFRB treatment (Twohig & Capel, 2025). A-EBT has the most research supporting treatment of trichotillomania, and there is a growing field of research supporting A-EBT for the treatment of skin picking disorder. A-EBT has been found to reduce BFRB symptoms after treatment in 17 studies so far. Two large treatment studies found that 64% of participants with trichotillomania and 43% of participants with skin picking disorder were considered treatment responders after A-EBT, meaning they were considered very much improved or much improved (Asplund et al., 2025; Woods et al., 2022). A-EBT has also been found to reduce psychological inflexibility, which plays a role in maintaining BFRB symptoms through its relationship with shame and mood-related symptoms, such as anxiety and depression.

A-EBT is also effective through online delivery using both synchronous telehealth visits with a therapist and asynchronous self-guided programs. Two studies of telehealth-delivered A-EBT for trichotillomania have shown promising results of significant symptom reduction among both adults and adolescents. Four online asynchronous A-EBT programs have also shown symptom reduction of trichotillomania and skin picking among adults. One study included an asynchronous A-EBT intervention as a first step, followed by telehealth-delivered A-EBT, which similarly provided promising results for trichotillomania symptom reduction.

Much of the research on A-EBT has been focused on individual treatment of BFRBs. However, two studies have provided support for group-based delivery of A-EBT with significant symptom reduction in both trichotillomania and skin picking disorder. One of these studies even found that 60% of participants maintained their symptom reduction one year after treatment (Haaland et al., 2017). We are working to contribute to research on group-delivered A-EBT through voluntary participation in a research study assessing outcomes of our own BFRB class through Juniper Mental Health.