ComB model · Atlas

1. Introduction

Version followed: the four-phase, ten-step model of Mansueto, Golomb, Thomas & Stemberger (1999), using the later SCAMP labels (Sensory, Cognitive, Affective, Motor, Place) and the separate relapse-prevention phase as presented by Mansueto & Golomb (IOCDF expert article) and Golomb & Mouton-Odum (IOCDF 2023 presentation). The 2023 Cambridge clinical guide (Mansueto, Mouton-Odum & Golomb) was seen only as a table of contents and description; the 12-session research manual (Falkenstein et al., 2016) was seen only through its abstract and a published adaptation (Bottesi et al., 2020). [uncertain: chapter-level detail of the 2023 book]

The Comprehensive Behavioral (ComB) model is a functional-analytic framework for treating body-focused repetitive behaviours (BFRBs): hair pulling (trichotillomania), skin picking (excoriation disorder), and nail, cheek or lip biting and similar behaviours. It is a framework for building an individual treatment, not a fixed package: the therapist and client map what triggers the behaviour and what rewards it across five domains (SCAMP), then choose strategies that block, replace or remove those triggers and rewards. Change is assumed to come from interrupting a learned, reinforced habit pattern and substituting healthier behaviours that meet the same need for that person, rather than from willpower or insight into deep causes. It extends habit reversal training (HRT) by covering sensory, cognitive, affective and environmental drivers that HRT's competing response alone does not reach. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; TLC Foundation Expert Consensus Guidelines, 2016]

Scope: individual outpatient treatment of adults, adolescents and children (with family adaptations). The model was presented in 1999 as untested; a manual and uncontrolled pilot followed (Falkenstein et al., 2016); controlled trials were reported as under way. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF]

2. Framework

Naming note: the 1999 paper names the five modalities cognitive, affective, motoric, sensory and environmental; later sources use Motor and Place (environment). The 1999 paper has four phases (evaluation and relapse prevention together in Phase 4); the 2023 IOCDF presentation lists five components with relapse prevention as its own phase. Content is the same; this guide uses the five-part layout. [source: Mansueto et al., 1999; Golomb & Mouton-Odum, 2023]

Phase I. Assessment and functional analysis (1999 Steps I–III)

Goals: decide together that the BFRB itself is the target; orient the client to a learning-based model; assess readiness and co-occurring conditions; map antecedents, the behaviour sequence and consequences; start self-monitoring.
Functional components assessed: antecedents (external settings and implements; internal feelings, sensations and thoughts), discriminative cues (private places, tools, postures, permission-giving thoughts), the behaviour chain (preparation, e.g. going to a place or searching for a hair; removal, i.e. selecting and pulling or picking; disposition, i.e. discarding, keeping, examining, or oral/tactile play with the hair or skin), and consequences (pleasant sensation, goal completion, relief of tension or boredom, escape; and aversive outcomes such as shame that end an episode).
Move on when: the client has agreed that the BFRB is the treatment focus, any crisis or co-occurring problem that would block work has been dealt with or planned for, and self-monitoring has produced enough episodes to see a pattern. [source: Mansueto et al., 1999] No minimum monitoring period is given in the sources; one to two weeks is a common practical choice. [synthesis]

Phase II. Identify and target domains (Steps IV–V)

Goals: place each functional finding into its SCAMP domain (a components-by-modalities grid); pick the domains to target first, favouring those that are most frequent, most powerful, or easiest to change. Several domains are usually involved.
Move on when: the client recognises the map as accurate and two or three priority domains are agreed. [source: Mansueto et al., 1999; Golomb & Mouton-Odum, 2023] [synthesis: the "two or three" figure]

Phase III. Identify, choose and implement strategies (Steps VI–VIII)

Goals: offer a menu of strategies for each targeted domain; the client chooses; the therapist explains the rationale and coaches use; strategies are used for at least one week, applied in high-risk situations before urges arise. Place and sensory strategies are usually brought in early because they act quickly and build motivation.
Move on when: a week of strategy use and monitoring is available to judge. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; Golomb & Mouton-Odum, 2023]

Phase IV. Evaluation and modification (Steps IX–X)

Goals: review each strategy weekly against monitoring data; rate goals as met, partly met or not met; keep, add, modify or replace strategies. Before dropping a strategy, check whether it was actually used and what got in the way.
Phases III and IV cycle weekly until goals are met. [source: Mansueto et al., 1999; Golomb & Mouton-Odum, 2023]

Phase V. Relapse prevention, maintenance and termination

Goals: shift from therapist guidance to self-management; keep supplies stocked; move to lower-effort strategies; plan for predictable high-risk periods; define what counts as a relapse; keep a written list of effective strategies; arrange booster sessions.
Termination follows agreed goals; sessions fade from weekly to fortnightly, monthly, then phone check-ins. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF]

Session count and format

1999 cases: one client had about eight sessions then monthly visits; another had about six months of weekly sessions. [source: Mansueto et al., 1999]
Research manual: 12 sessions in four sections (assessment, modality identification, specific interventions, evaluation and relapse prevention); one published adaptation compressed it to eight weekly 90-minute sessions (psychoeducation and domain mapping; stimulus control and HRT; three sessions of cognitive restructuring and behavioural experiments; stress management; relapse prevention; review), with between-session tasks and a handout each week. [source: Bottesi et al., 2020, describing Falkenstein et al., 2016] [uncertain: session-by-session content of the original 12-session manual not seen]
Format: individual, weekly; parents heavily involved for children up to about 12, less in adolescence. [source: Golomb & Mouton-Odum, 2023; TLC Guidelines, 2016]

3. Guiding principles

[source for this section: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; Golomb & Mouton-Odum, 2023; TLC Guidelines, 2016, unless marked]

Treat the function, not the form. Choose strategies by what the behaviour does for this person, not by whether it is pulling or picking.
Individualise; no fixed package. Two clients with the same diagnosis may get entirely different strategy sets.
Flexible within a system. The authors call the approach "creative and fluid rather than rigidly applied" (Mansueto & Golomb, IOCDF); the phases still give the order of decisions.
Collaborative division of labour. The therapist supplies the model, the functional analysis and the strategy menu; the client chooses, implements and monitors.
Data over recall. Self-monitoring is the main assessment tool and is preferred to retrospective interview; revise the form as treatment moves on.
Typology is not enough. Automatic versus focused pulling describes awareness, but you still need the full SCAMP map to choose interventions.
Normalise and de-shame. Present BFRBs as common, learned and functional; correct myths; change does not require extraordinary willpower.
Readiness is not motivation. A client can want to stop yet lack the time or stability to work on it now; assess readiness and timing openly.
Act before the urge. Strategies are put in place for high-risk situations in advance, not only when the urge appears.
Give each strategy a fair trial. At least one week of actual use before judging it.
Combine domains. Most clients need strategies from several domains at once.
Quick wins first. Place and sensory strategies early, to build momentum.
Strategies only work if used. Track strategy use as closely as the behaviour itself.
Measure behaviour change, not appearance. The goal is strategy use and fewer episodes, not hair regrowth or clear skin.
Expect slips. In the guidelines' words, "slips are often a normal part of the landscape and should be expected" (TLC, 2016); treat a slip as information, not failure.
Address the whole person. Shame, avoidance, relationships, perfectionism and co-occurring disorders need attention alongside the BFRB, not instead of it.
Wean, don't stop abruptly. Reduce strategies as gains hold, moving to less effortful ones.

4. Intervention inventory

The inventory has three parts: (A) the process procedures that run the model, (B) the domain strategies grouped by SCAMP, and (C) maintenance, self-care and family procedures. The domain lists follow the 1999 strategy table, the IOCDF expert article and the 2023 presentation; where only one source lists an item, that source is named. In ComB these strategies are a menu: the client picks from it to fit their own functional analysis, and does not work through every item. All example language is illustrative unless quoted.

A. Process procedures

A1. Decision, orientation and psychoeducation

Purpose: agree that the BFRB itself is the target, give a learning-based model of the problem, reduce shame, and judge readiness. Use in the first session(s) and again whenever motivation dips. [source: Mansueto et al., 1999, Step I; Golomb & Mouton-Odum, 2023]
Steps:
1. Screen for co-occurring problems (depression, anxiety, ADHD, OCD, tics, personality problems, crises) and decide with the client whether any must come first. Rule out other explanations (dermatological or medical causes, substances, body dysmorphic disorder, non-suicidal self-injury, psychosis, delusional parasitosis, stereotypic movement disorder). [source: TLC Guidelines, 2016; Phelps & Bethurem, 2022]
2. Ask whether the client swallows or chews hair; if hair is swallowed, arrange prompt medical review because of trichobezoar risk. [source: TLC Guidelines, 2016]
3. Explain prevalence, that BFRBs are not self-harm and are not usually a sign of hidden trauma, and that the behaviour persists because it does something useful for the person in the moment.
4. Explain the plan: map triggers and payoffs, choose strategies, test them for a week at a time, keep what works.
5. Set expectations: progress is gradual, slips are expected, and the target is behaviour change, not how the hair or skin looks.
6. Discuss readiness: time, competing priorities, and willingness to monitor. Point to support groups and TLC Foundation resources.
Example language (illustrative): "Pulling isn't a lack of willpower. It's a habit that pays off for you in some way, maybe calming you or giving a satisfying feeling. Our job is to work out exactly what it does for you and find other ways to get that, or to make pulling harder in the moments it usually happens."
Watch for: shame-driven minimising; a parent or partner who is more motivated than the client; perfectionistic expectations of stopping completely. Working if the client can describe the behaviour openly and agrees to monitor.

A2. Functional assessment interview (SCAMP interview)

Purpose: build the antecedent–behaviour–consequence map across all five domains. Use in Phase I; repeat after any relapse. [source: Mansueto et al., 1999, Step II; Phelps & Bethurem, 2022; Golomb & Mouton-Odum, 2023]
Steps:
1. Ask the client to walk you slowly through a typical recent episode from before it started to after it ended.
2. Sensory: visual cues (a hair or skin spot that looks wrong), itch or tingling, how the hair or skin feels, taste, smell, sounds of pulling or popping, skin conditions that raise body awareness, inspecting the site before, during or after, substances or medications that raise restlessness.
3. Cognitive: beliefs about the behaviour ("that hair doesn't belong"), need for evenness or perfection, permission-giving thoughts ("just one", "I deserve it after today"), wider stressors.
4. Affective: emotions before, during and after (tension, boredom, sadness, frustration, indecision, excitement, relief, guilt, shame). Do not assume anxiety.
5. Motor: automatic, focused or both; postures (hand to head while reading, lying in bed); pre-behaviour rituals (stroking, searching, feeling for a hair); the full chain from first movement to disposal of the hair or skin.
6. Place: rooms, times of day, activities (driving, reading, screens, phone calls, studying), being alone or with others, tools (tweezers, magnifying mirrors, bright light).
7. Consequences: what feels good or gets achieved; what ends the episode (noticing, guilt, interruption); any attention from others (more common in children).
Example language (illustrative): "Let's slow it right down. Where were you, what were your hands doing just before, and what was the very first thing you noticed?"
Watch for: clients who can't recall because pulling is automatic; that itself tells you the motor/awareness domain is a target, so lean on self-monitoring. Working if you can say for each domain whether it is relevant and how.

A3. Self-monitoring

Purpose: the main assessment tool and the ongoing outcome measure; also builds awareness. Use from Phase I to the end. [source: Mansueto et al., 1999, Step III; Golomb & Mouton-Odum, 2023]
Steps:
1. Give a simple form. The 2023 presentation's form records date and time, place, behaviour, sensory input, thoughts, feelings, motor behaviour, duration, and 1–4 ratings of awareness and severity; the companion strategy form adds which strategy was used and for how long. (Describe in your own format; the authors' forms are in their materials.)
2. Train the client in session: complete one entry together for a recent episode.
3. Ask for entries as soon as practical after each episode (or at set times for frequent, automatic behaviour).
4. Review the forms at the start of every session; look for repeating triggers and payoffs.
5. Revise the form as treatment progresses (for example, add strategy-use columns, drop columns that are no longer useful).
Adaptation seen in one study: daily records of episodes, hairs pulled per episode, and 0–10 ratings of urge resistance and distress. [source: Bottesi et al., 2020]
Example language (illustrative): "This isn't a report card. Every entry, including the bad days, gives us information we can use."
Watch for: incomplete or retrospective forms; shame about recording. Working if forms show patterns you can act on and the client starts noticing earlier links in the chain.

A4. Components-by-domains grid and target selection

Purpose: turn the assessment into treatment targets. Use at the end of Phase I / Phase II. [source: Mansueto et al., 1999, Steps IV–V; Golomb & Mouton-Odum, 2023]
Steps:
1. Draw a grid: functional components (triggers, cues, behaviour chain, consequences) down one side; S, C, A, M, P across the top.
2. Place each finding in its cell (boredom or anxiety under Affective; symmetry thoughts under Cognitive; itch or pleasant sensation under Sensory; mirrors or tweezers under Place; hand-to-head posture under Motor).
3. With the client, mark the domains that are most frequent, most powerful and most changeable.
4. Agree the starting targets.
Example language (illustrative): "Looking at this together, the bathroom mirror and that rough-hair feeling seem to start most episodes, and the relief afterwards keeps it going. Shall we start there?"
Watch for: a grid crowded into one domain because the client only reports emotions or only reports habits; ask about all five. Working if the client recognises the map as theirs.

A5. Strategy menu, choice and coaching

Purpose: match strategies to targets and make sure the client can actually use them. Use in Phase III. [source: Mansueto et al., 1999, Steps VI–VIII; Mansueto & Golomb, IOCDF; Golomb & Mouton-Odum, 2023]
Steps:
1. For each target domain, offer several strategy options (sections B1–B5).
2. Let the client choose; favour options that fit their lifestyle and preferences.
3. Explain why each chosen strategy should help, in terms of the trigger or payoff it targets.
4. Rehearse in session (practise the competing response, try sensory objects, plan exactly where blocks will be kept).
5. Plan use in high-risk situations before urges start, for at least a week.
6. Put it in writing on the strategy-use form.
Therapy simulation: in training, clinicians practise turning functional findings into recommendations and checking fit. [source: Golomb & Mouton-Odum, 2023] You can use the same check with clients: read back the trigger and ask whether the strategy would plausibly change it. [synthesis]
Example language (illustrative): "Here are four ideas for the car. Which one could you actually see yourself doing every time you drive this week?"
Watch for: too many strategies at once; strategies that need willpower in the moment rather than set-up in advance. Working if the client leaves with two to four concrete, located strategies. [synthesis: the number]

A6. Weekly evaluation and modification

Purpose: keep, add, change or drop strategies based on data. Use every Phase III–IV session. [source: Mansueto et al., 1999, Steps IX–X; Golomb & Mouton-Odum, 2023]
Steps:
1. Review behaviour monitoring and strategy-use records together.
2. For each strategy: was it used, how often, where? If not used, find the barrier first and fix it before judging the strategy.
3. Rate the week's goals: met, partly met, not met.
4. Decide: keep effective strategies; modify (for example, a client who pulls despite gloves in bed tries socks on the hands instead, per the 1999 paper); add; or replace.
5. Set the next week's plan.
Example language (illustrative): "Before we decide the fidget didn't work, let's look at how many times it was actually in your hand when you were studying."
Watch for: abandoning strategies after one bad day; the client blaming themselves rather than the fit of the strategy. Working if episodes, duration or severity fall and strategy use rises.

B. Domain strategies: Sensory

B1. Sensory substitution

Purpose: give the hands, mouth or skin the sensation the behaviour supplies, without damage. Use when the payoff is tactile, oral or visual (the feel of a coarse hair or a bump, rolling a hair between fingers, biting or chewing hair). [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; Golomb & Mouton-Odum, 2023; TLC Guidelines, 2016]
Steps:
1. From the interview, name the exact sensation (rough, smooth, stringy, popping, crunchy, a scalp tingle).
2. Brainstorm matching objects. Examples from the sources: textured brushes, Koosh-type balls, putty, squeeze toys, smooth stones, dental floss (for a hair-like feel), head massagers, a wide-tooth comb for scalp itch, scents, chewing gum, lip balm, crunchy snacks such as sunflower seeds or carrots, a smooth covering over scabs.
3. Try several in session; the client rates how close each feels.
4. Place chosen items where the behaviour happens (desk, car, bedside, sofa).
Example language (illustrative): "When you roll the hair between your fingers, what's the best part of the feeling? Let's find something that gives you that."
Watch for: substitutes that turn into damage (picking at putty with nails then moving to skin, chewing that leads to lip biting); food substitutes in clients with eating difficulties (choose non-food options). [synthesis: the cautions] Working if the item is in hand during high-risk times and urges are satisfied or shortened.

B2. Sensory distraction

Purpose: give the senses competing input so the trigger sensation is less noticeable. Use when sensations (itch, tingle) start episodes or during idle sensory states. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF]
Steps:
1. Identify when trigger sensations peak.
2. Choose pleasant sensory input for those times (baths, massage, face masks, music, scents are examples given in the 1999 table and the IOCDF article).
3. Schedule it for those times rather than waiting for the urge.
Example language (illustrative): "Evenings after work are when the scalp starts tingling. What could give your senses something else to do then?"
Watch for: distraction that becomes avoidance of all quiet time. Working if trigger sensations are noticed less or fade without action.

B3. Sensory extinction and prolonged sensory exposure

Purpose: reduce the pull of a trigger sensation by letting it be present without acting on it, so the link weakens. Listed in the 1999 strategy table; no step-by-step procedure is given in the sources. [source: Mansueto et al., 1999] [uncertain: procedure]
Steps (derived from standard exposure practice) [synthesis]:
1. Get informed consent: explain that the sensation and urge will rise and then fall, and that the client stays in control and can stop.
2. Choose a mild trigger (touching a coarse hair without pulling, looking at a skin spot without touching).
3. Hold contact or attention with the sensation while keeping hands still, rating the urge (0–10) every minute or so, until it falls noticeably.
4. Repeat, then move up a ladder of stronger triggers.
Contraindications and safety [synthesis]: not when the client is in crisis, actively suicidal, severely dissociative, or when a skin wound is infected; stop if the session would end with damage; pair with blocks (gloves) at first.
Example language (illustrative): "Notice the hair under your fingertip. Let the urge be there. You don't have to do anything with it. What number is it now?"
Watch for: "testing" turning into pulling; this is a known relapse risk (see C2). Working if urge ratings fall within and across sessions.

B4. Reducing physical irritation

Purpose: remove the itch, dryness or bump that triggers the behaviour. Use when a skin or scalp condition, dry skin or ingrown hair is a trigger. [source: Mansueto et al., 1999; TLC Guidelines, 2016; Golomb & Mouton-Odum, 2023]
Steps:
1. Ask about skin, scalp and eye symptoms.
2. Refer to a dermatologist or GP when skin problems seem to drive the behaviour; topical options (for itch, acne, irritation) are a medical decision. No dosing here.
3. Suggest moisturiser to soften rough skin (IOCDF case example), gentle hair care, and professional shaping of eyebrows or dyeing of grey hairs if those hairs are targets (1999 table).
Example language (illustrative): "If the rough patches are what draw your fingers, softening them might take away part of the trigger."
Watch for: inspecting skin while applying creams turning into picking; set a time limit and a no-mirror rule. [synthesis] Working if fewer episodes start from that sensation.

B. Domain strategies: Cognitive

B5. Cognitive correction and restructuring

Purpose: change beliefs and permission-giving thoughts that start or justify episodes. Use when the map shows rules ("coarse hairs must go", "a bump has to be popped"), perfectionism, or permission-giving ("just one", "I'll stop tomorrow"). [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; TLC Guidelines, 2016; Golomb & Mouton-Odum, 2023]
Steps:
1. Use monitoring records to catch the exact thought before or during episodes.
2. Examine it: evidence from past episodes, cost-benefit, what happens when the client acts on it.
3. Write a corrected version based on the client's own history (the 1999 example: the client learns that one hair never stays one).
4. Rehearse the corrected thought for high-risk times.
5. For perfectionism, consider broader CBT for perfectionism. [source: Phelps & Bethurem, 2022]
Example language (illustrative): "When you told yourself 'just this one', how many did it turn out to be last week? What's a more accurate thing to tell yourself next time?"
Watch for: intellectual agreement without change in the moment; pair with motor and place strategies. Working if clients catch the permission-giving thought before acting.

B6. Coping self-statements

Purpose: short prepared phrases to use at the moment of urge or cue. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF]
Steps:
1. Draft two or three short statements with the client in their own words.
2. Put them on a card, phone lock screen or mirror cover.
3. Practise saying them while imagining a typical cue.
Example language (illustrative): "An urge is a feeling, not an order. It will pass."
Watch for: statements that sound like scolding. Working if the client uses them and reports a pause before acting.

B7. Thought stopping

Purpose: interrupt the thought chain. Listed in the 1999 table (with the example of snapping a rubber band). [source: Mansueto et al., 1999]
Steps: the client notices the triggering thought, says "stop" silently or aloud, and switches to a planned activity or coping statement.
Note: later ComB sources (IOCDF article, 2023 presentation) list cognitive restructuring and acceptance-based strategies instead and do not list thought stopping; current CBT practice generally prefers acceptance and restructuring to suppression. [synthesis] Avoid using pain (rubber band snapping) with clients who pick or pull to self-punish or have self-harm histories. [synthesis] [uncertain: whether the 2023 book retains it]
Watch for: rebound of suppressed thoughts. Working only if it creates a brief gap in which another strategy is used.

B8. Mindfulness, acceptance and urge surfing

Purpose: let urges, sensations and emotions be present without acting; useful when urges are strong or when suppression backfires. [source: Mansueto & Golomb, IOCDF; Golomb & Mouton-Odum, 2023; TLC Guidelines, 2016 (ACT and DBT components)]
Steps:
1. Teach noticing: name the urge, where it is in the body, its strength.
2. Urge surfing: watch the urge rise, peak and fall, while keeping hands occupied or still.
3. Values link (ACT-enhanced variant): clarify what matters to the client and whether pulling moves them toward or away from it; commit to tolerating discomfort in service of those values.
4. Practise daily, outside high-risk times, before using in them.
Example language (illustrative): "Notice the urge like a wave. You don't have to fight it or obey it. Just watch it change."
Watch for: clients using mindfulness to watch themselves pull. Pair with a block or competing response at first. [synthesis] Working if the client can sit with an urge without acting.

B9. Behavioural experiments

Purpose: test beliefs about the behaviour directly (for example, "if I don't pull this hair I won't be able to concentrate"). Used in one published adaptation of the ComB manual; not listed in the 1999 table. [source: Bottesi et al., 2020] [uncertain: status in the original manual]
Steps: name the belief and a prediction; design a test (study for 30 minutes with gloves on and rate concentration); run it; compare result with prediction; update the belief.
Example language (illustrative): "Let's find out. What do you predict will happen to your focus if you study without touching your hair for half an hour?"
Working if predictions are disconfirmed and the belief rating drops.

B. Domain strategies: Affective

B10. Relaxation and controlled breathing

Purpose: lower tension so the behaviour is not needed to discharge it. Use when tension, anxiety or frustration precede episodes. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; Golomb & Mouton-Odum, 2023; Bottesi et al., 2020]
Steps:
1. Teach progressive muscle relaxation: tense and release major muscle groups in sequence, noticing the contrast.
2. Teach slow breathing: slower, longer out-breath, a few minutes at a time.
3. Practise daily at neutral times; then use at known high-risk times (studying, driving, after work) and at the first sign of tension.
Example language (illustrative): "Let's practise when you're calm, so it's ready when the tension shows up at your desk."
Watch for: relaxation used only after pulling has started. Working if tension ratings before episodes drop and episodes linked to tension fall.

B11. Self-hypnosis and positive visualisation

Purpose: calming and rehearsal of coping. Listed in the 1999 table (self-hypnosis, positive visualisation) and the IOCDF article (positive visualisation). [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF]
Steps: guide the client to imagine a high-risk scene in detail and see themselves noticing the cue, using their chosen strategy and getting through the urge; practise between sessions. Self-hypnosis requires your own training in it. [synthesis: the scene-rehearsal format]
Example language (illustrative): "Picture yourself at the desk. You feel your hand rising. See yourself pick up the stone instead."
Note: the TLC guidelines do not recommend hypnosis as a stand-alone treatment; here it is only an adjunct. [source: TLC Guidelines, 2016]
Working if the client reports using the rehearsed response in the real situation.

B12. Lifestyle and stress-management skills

Purpose: reduce the background stress, boredom and under-stimulation that feed the behaviour. [source: Mansueto et al., 1999 (exercise, assertiveness, time management, problem solving); Golomb & Mouton-Odum, 2023 (exercise, stress management, assertiveness training)]
Steps:
1. From monitoring, find the life patterns behind affective triggers (idle evenings, procrastination, conflict avoided).
2. Pick the matching skill: structured problem solving, time management, assertiveness practice, regular physical activity, more engaging activities in boring periods.
3. Set one small, specific weekly step.
Example language (illustrative): "Most of your picking happens when you're putting off the assignment. Let's plan how you break it into pieces."
Watch for: becoming general life coaching while the BFRB is ignored; keep monitoring the behaviour. Working if affective triggers become less frequent.

B13. Emotion regulation and distress tolerance (DBT and ACT skills)

Purpose: give other ways to manage strong or unwanted emotions. Use when emotional dysregulation, low distress tolerance or impulsivity are central. [source: Mansueto & Golomb, IOCDF; Golomb & Mouton-Odum, 2023; TLC Guidelines, 2016; Phelps & Bethurem, 2022]
Steps (skills as summarised in the TLC guidelines; teach them from DBT or ACT materials):
1. Identify and label emotions in the chain.
2. Reduce vulnerability (sleep, eating, activity, positive events).
3. Mindfulness of current emotion.
4. Opposite action where the emotion's action urge doesn't fit.
5. Distress tolerance: getting through a crisis or urge without making it worse.
6. Values clarification and willingness (ACT): tolerate discomfort in service of what matters.
Example language (illustrative): "What was the feeling just before? If we name it, we can pick a skill that fits it instead of pulling."
Watch for: clients needing a full DBT programme rather than borrowed skills; refer if so. Working if emotion-linked episodes fall and the client uses skills in the moment.

B14. Exposure to unwanted hairs (in vivo or imaginal)

Purpose: reduce distress caused by hairs or skin features the client feels must be removed. Listed under affective strategies in the 1999 table; no detailed procedure given in the sources. [source: Mansueto et al., 1999] [uncertain: procedure]
Steps (derived from standard exposure practice) [synthesis]:
1. Consent: explain rationale (distress about the 'wrong' hair falls with repeated contact without removal), that it will be uncomfortable for a while, and that the client sets the pace.
2. Build a short hierarchy (looking at an uneven hairline, leaving a grey hair in place for an hour, then a day; imagining leaving it).
3. Stay with each step, rating distress, until it falls; no removal, no checking. Remove tweezers and use blocks during practice.
4. Repeat until distress is low, then move up.
Contraindications and safety [synthesis]: postpone during crises, active suicidality, uncontrolled substance use or severe dissociation; screen for body dysmorphic disorder first (then follow BDD-specific treatment); do not run in a way that risks the session ending in damage.
Example language (illustrative): "Leave that hair where it is. Notice how much it bothers you right now, from 0 to 10. We'll check again in a few minutes."
Working if distress about the target falls and checking reduces.

B. Domain strategies: Motor

B15. Awareness training

Purpose: make automatic behaviour noticeable early in the chain. Use when pulling or picking happens without awareness. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; TLC Guidelines, 2016; Golomb & Mouton-Odum, 2023]
Steps:
1. Map the movement chain from the interview and monitoring: first hand movement, touching, searching, posture.
2. Practise noticing in session: the client describes the movement while doing it slowly (without pulling), and you signal when you see an early movement.
3. Add physical awareness cues: fingertip bandages, scent on wrists or fingers, an elastic elbow brace (makes bending the arm to the head noticeable), rings, or a wearable that vibrates on hand-to-face movement (2023 presentation names a commercial device). Biofeedback is listed in 1999.
4. Continue self-monitoring, which itself builds awareness.
Example language (illustrative): "Show me how your hand usually gets to your eyebrow. Slowly. Where's the first moment you could notice it?"
Watch for: awareness rising without a plan for what to do next; pair with B16–B18. Working if the client catches more episodes before any hair or skin is removed.

B16. Response prevention (blocks)

Purpose: make the behaviour physically harder or interrupt it. Use for automatic behaviour and predictable high-risk activities. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; TLC Guidelines, 2016; Golomb & Mouton-Odum, 2023]
Steps:
1. Choose blocks matched to site and situation: gloves, finger tape or bandages, hats, scarves, bandannas, long sleeves, eye masks at night, wet or styled hair that is hard to grip, trimmed nails, covering picking sites with clothing.
2. Decide when to put them on (before reading, driving, bed), not after an urge starts.
3. Keep them where the situation happens.
Example language (illustrative): "If you put the gloves on before you open the laptop, you don't have to decide anything in the moment."
Watch for: getting round the block (gloves removed, pulling with the other hand); modify, for example socks on hands in bed. Working if episodes in blocked situations fall.

B17. Competing response training (HRT)

Purpose: replace the movement with one that is incompatible with it. Use when urges or early movements are recognisable. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; TLC Guidelines, 2016]
Steps:
1. Pick a response that can't be done at the same time as pulling or picking, is inconspicuous, and can be held for about a minute: for example making fists, tensing the arm muscles and locking the arms by the sides, or holding an object.
2. Practise in session on cue.
3. Use it at each urge, early movement or entry into a trigger situation; hold until the urge passes.
4. Social support: a trusted person praises use of the response and gently prompts it in high-risk situations (agree how first).
Example language (illustrative): "As soon as you feel your hand lift, press your fingertips into your palm and hold until the urge eases."
Watch for: the response becoming a new automatic habit or a cue to pull; fade it as other strategies take over (the 1999 case dropped fist-clenching by session five). Working if urges pass without pulling.

B18. Hand-occupying activities

Purpose: keep hands busy in idle high-risk times. [source: Mansueto et al., 1999 (crafts such as knitting, worry beads, putty); Mansueto & Golomb, IOCDF (fidget toys)]
Steps: choose an activity or object for each high-risk activity (fidget while studying, knitting while watching TV, steering-wheel grip while driving); keep it at hand.
Example language (illustrative): "What could your hands be doing while you watch TV?"
Watch for: the object left in a drawer. Working if idle-time episodes fall.

B19. Changing postures and pre-behaviour rituals

Purpose: break the chain at its early, habitual links. [source: Golomb & Mouton-Odum, 2023; Phelps & Bethurem, 2022]
Steps: identify typical postures (head propped on hand, lying in bed reading) and rituals (stroking hair, scanning skin); plan an alternative posture or action for each (sit upright with both hands on the book, read at a table, keep hands below shoulder height).
Example language (illustrative): "Your hand on your head while reading seems to be the starting point. What if you read at the table with the book flat?"
Working if the early links occur less.

B. Domain strategies: Place

B20. Stimulus control

Purpose: change the environment so cues and tools are absent or the behaviour is harder. Use when places, times, tools or being alone set off episodes. Often introduced early for quick results. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; TLC Guidelines, 2016; Golomb & Mouton-Odum, 2023; Phelps & Bethurem, 2022]
Steps:
1. List high-risk places, times and tools from monitoring.
2. Change each one: cover or remove mirrors (especially magnifying ones), dim bathroom lights, remove tweezers, limit bathroom time, watch TV or study in another room or in a library or lounge rather than alone, sit near the front of a class, keep blocks or a hat in the car.
3. Plan replacements for activities that will continue (reading, driving, phone calls).
Example language (illustrative): "The magnifying mirror seems to start most of the picking. Would you be willing to put it away for the week and see what happens?"
Watch for: replacement mirrors (phone camera); family members undoing changes. Working if episodes in those places fall.

B21. Contingency management

Purpose: add rewards for strategy use or penalties for the behaviour, to strengthen new habits. Also use when attention from others reinforces the behaviour (more common in children). [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF; TLC Guidelines, 2016]
Steps:
1. Choose what to reward; for children, guidelines say reward strategy use rather than absence of pulling.
2. Set rewards (or agreed penalties, or self-administered covert contingencies) and who delivers them.
3. Optional accountability: the 1999 paper lists showing collected hairs to the therapist.
4. Where attention reinforces the behaviour, coach others to give attention to strategy use instead.
Example language (illustrative): "Each day you wear the gloves for your evening reading, you earn a point toward the thing you're saving for."
Watch for: shame from penalties or hair-showing; drop anything that adds shame. [synthesis] Working if strategy use rises.

C. Maintenance, self-care and family procedures

C1. Maintenance and weaning

Purpose: keep gains while reducing effort. Use once goals are mostly met. [source: Mansueto et al., 1999; Mansueto & Golomb, IOCDF]
Steps:
1. Keep supplies stocked (gloves, fidgets, bandages, moisturiser).
2. Withdraw strategies one at a time, starting with the most effortful, while monitoring continues.
3. Move to lighter strategies (a ring as a reminder rather than full gloves). [synthesis: the example]
4. Fade sessions: weekly, fortnightly, monthly, then phone check-ins.
Example language (illustrative): "You've had four steady weeks. Which strategy would you like to try dropping first, while we keep watching the records?"
Watch for: behaviour returning when a strategy is withdrawn; reinstate it. Working if gains hold at each step.

C2. Relapse prevention plan

Purpose: prepare for lapses so they don't become full relapses. [source: Mansueto et al., 1999; TLC Guidelines, 2016; Golomb & Mouton-Odum, 2023]
Steps:
1. Define with the client what a lapse is and what a relapse is.
2. List predictable high-risk times (stress, illness, holidays and travel, exams, hormonal changes, regrowth of hair, new skin blemishes) and the risk of "testing" oneself by touching or examining.
3. Write down the strategies that worked, by domain, and keep the list somewhere easy to find.
4. Plan a response to a slip: note what happened, redo a mini functional analysis, reinstate strategies, contact the therapist if needed.
5. Offer booster sessions.
6. After a relapse, review whether the same functional factors are at work or new ones have appeared.
Example language (illustrative): "If you have a bad night in six months, what will you tell yourself, and what's the first thing you'll do the next morning?"
Watch for: all-or-nothing thinking, wait-and-see responses to slips. Working if the client handles a lapse with problem solving rather than giving up.

C3. Hair and skin self-care

Purpose: support healing and reduce physical triggers; help clients care for the affected area without it becoming a cue. The 2023 book has a chapter on self-care during and after treatment and covers healthy hair and skin care. [source: Cambridge book description, 2023; TLC Guidelines, 2016] [uncertain: chapter content]
Steps (from guidelines): keep picked wounds clean and protected to prevent infection (antibiotic cream as advised medically); consult a dermatologist where skin problems drive the behaviour; consider a BFRB-aware hair or skin-care professional; watch for repetitive strain injury. Cover healing sites (smooth dressings) so they are less tempting.
Example language (illustrative): "Covering it while it heals protects the skin and takes away the bump your finger looks for."
Watch for: grooming routines that become extended examining; set time limits and lighting rules. [synthesis]

C4. Working with children and families

Purpose: adapt ComB for children and adolescents and use family support well. [source: Golomb & Mouton-Odum, 2023; TLC Guidelines, 2016; Cambridge book description, 2023]
Steps:
1. Ages 0–5: parents run the strategies at home with your guidance. Ages 6–11: parents heavily involved; reward strategy use, not absence of pulling. Ages 12–14: involve the young person in designing strategies; guide parents on how much to help. Ages 15–18: more privacy, less parent contact with you, time to build the teen's own engagement; parents may need their own support.
2. Take parents out of the "police" role; address their anxiety and accommodation; teach them to prompt and praise instead of criticising.
3. Make treatment fun; rewards such as fidget toys; treat slips as problems to solve.
4. Watch for attention as a reinforcer; redirect attention to strategy use.
5. Very early-onset pulling may resolve by itself but also responds to treatment.
6. See the child as a whole person, not as a BFRB.
Example language to parents (illustrative): "Instead of 'Stop pulling', try 'Want your putty?' and notice out loud when she's using it."
Watch for: parents more motivated than the child; family conflict over the behaviour; spouse or partner comments that help in one way and hurt in another (1999 paper calls this double-edged). Working if the child uses strategies with less prompting and family tension falls.

5. Handling problems

Non-adherence (most common problem). [source: Mansueto et al., 1999; Golomb & Mouton-Odum, 2023]

Causes named by the authors: crises, competing priorities, wanting to focus on other problems. Response: discuss goals and priorities frankly; the client makes the final decision about timing; pause BFRB work during crises and return to it after.
Before deciding a strategy failed, ask whether it was used; identify the barrier (forgot, embarrassing, not available, too effortful) and modify. Strategies only work if used.
Make strategies need less in-the-moment willpower: set-up in advance, placement in the situation, cues (phone reminders, sticky notes). [synthesis]

Poor acceptance, shame and avoidance. [source: Mansueto et al., 1999; TLC Guidelines, 2016]

Use education, reading material from the TLC Foundation and IOCDF, support groups, and cognitive work on shame. Address shame, isolation and avoided goals directly, because they rarely resolve by themselves.
If shame blocks monitoring, start with monitoring of strategy use only, then add episodes. [synthesis]

Motivated but not ready. [source: Golomb & Mouton-Odum, 2023]

Separate wanting change from being able to put in the work now. Agree a start date or a smaller first step (one place strategy) rather than forcing a full plan. [synthesis: the small-step option]

Stuck: no progress after several weeks. [synthesis unless noted]

Re-check the functional analysis: a domain may be missed (sensory or cognitive drivers often under-reported), or the payoff is different from what you assumed. After relapse the authors also advise reviewing the analysis. [source: Mansueto et al., 1999]
Check whether strategies target the right point in the chain (preparation vs removal vs disposal).
Look for co-occurring problems driving episodes (depression, ADHD, OCD, BDD, substance use) and treat or refer. [source: Mansueto et al., 1999; TLC Guidelines, 2016]
Consider adding acceptance-based (ACT) or DBT skills, or a medical review; medication is a prescriber decision. [source: TLC Guidelines, 2016]

Perfectionism about recovery. [source: Golomb & Mouton-Odum, 2023]

Prepare clients in advance for uneven progress; frame goals as behaviour change, not complete abstinence or perfect hair or skin. Use cognitive restructuring on all-or-nothing beliefs.

Slips and relapse. [source: Mansueto et al., 1999; TLC Guidelines, 2016]

Normalise; analyse the slip; reinstate strategies; boosters. Warn against "testing" and against wait-and-see after a slip.

Overwhelm, high distress, emotional dysregulation. [synthesis, building on Mansueto & Golomb, IOCDF and TLC Guidelines, 2016]

Reduce the number of strategies to one or two; prioritise affective-domain skills; pause exposure-type work (B3, B14). If emotional dysregulation is broad, consider a fuller DBT referral.

Risk and differential issues. [synthesis, following standard practice]

BFRBs are not self-harm, but clients can also self-harm or be suicidal (especially with co-occurring depression). If skin damage seems intended to hurt, or the client voices hopelessness, do a standard suicide and self-harm risk assessment and safety plan; this takes priority over BFRB work. Do not use painful aversive techniques (rubber-band snapping) with these clients.
Swallowed hair: prompt medical review. Infected wounds or eye injury: medical care. [source: TLC Guidelines, 2016]

Ruptures. [synthesis]

Common triggers: the client feels blamed for not using strategies, or feels the therapist is fixated on the behaviour. Name it, own your part, revisit the client's goals, and re-frame non-use as information about the strategy, not the person.

Modality-specific difficulties. [synthesis unless noted]

Blocks bypassed: change the type, the location or the timing (socks instead of gloves in bed). [source: Mansueto et al., 1999]
Substitutes become new damage (biting nails on fidgets, chewing turned into cheek biting): pick a different texture or a non-oral option.
Competing response becomes automatic or cues pulling: rotate responses or fade sooner.
Strategies conspicuous or embarrassing (gloves at work): choose discreet ones (finger tape, ring, fidget in pocket).
Partners or parents policing: coach them on prompting and praise only on agreed terms. [source: Golomb & Mouton-Odum, 2023; Mansueto et al., 1999]
Hair regrowth or new blemishes trigger pulling or picking: predict this and plan extra strategies for the regrowth phase.

Sources

Sources:

Books and papers cited:

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, 23–43.
Mansueto, C. S., Mouton-Odum, S., & Golomb, R. G. (2023). Comprehensive Behavioral (ComB) Treatment of Body-Focused Repetitive Behaviors: A Clinical Guide. Cambridge University Press. [contents only seen]
Falkenstein, M. J., et al. (2016). Comprehensive behavioral treatment of trichotillomania: A treatment development study. Behavior Modification. [abstract only seen]
Mansueto, C. S., Townsley Stemberger, R. M., Thomas, A. M., & Golomb, R. G. (1997). Trichotillomania: A comprehensive behavioral model. Clinical Psychology Review, 17. [uncertain]
Azrin, N. H., & Nunn, R. G. (1973). Habit reversal: A method of eliminating nervous habits and tics. Behaviour Research and Therapy. [uncertain: cited for HRT origin]

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