Telepsychotherapy for Trichotillomania: A Randomized Controlled Trial of ACT-Enhanced Behavior Therapy

Treatment for trichotillomania over video-conference seems to be an effective potential alternative to seeing a therapist in person, especially for people who may be too ashamed, busy, or far to seek traditional treatment. Telepsychotherapy with ACT-enhanced behavior therapy improved hair-pulling symptoms, with some patients seeing continued results 3 months after treatment. Strangely enough, quality of life did not improve, either because the questionnaire used may not accurately measure quality of life, or the telepsychotherapy treatment may not address broad quality of life beyond trich severity. Patients reported high satisfaction with this style of treatment and their therapists overall, despite some technical difficulties with the video software.

Full Summary

Telepsychology has shown promise in treating a wide range of mental illnesses, including PTSD, schizophrenia, agoraphobia, and eating disorders. Given its ability to reach populations who normally can't access quality treatment, as well as its convenience for people who may be too ashamed or busy to attend traditional psychotherapy, the authors of this paper wanted to examine the utility of telepsychotherapy for trichotillomania. They conducted a randomized controlled trial using remote Acceptance and Commitment Therapy (ACT) -enhanced behavior therapy, which uses both conventional behavioral techniques for hair-pulling and techniques for improving psychological flexibility (meaning, the ability to prioritize central goals over temporary thoughts and impulses). 12 adults were randomized into 10 sessions of active treatment, and 10 into a waitlist condition, meaning they had the option to receive the same treatment as the active group after 12 weeks, and the authors predicted not only significant improvements in hair-pulling severity, but also in quality of life, psychological flexibility, and shame. Of note, all participants had to reside in Utah, because regulations on telepsychology practice vary in different states, and all remote sessions used a video conferencing software compliant with HIPAA (Vsee). Additionally, measures were taken to assess therapeutic alliance and patient satisfaction with the treatment, in order to determine the viability of the remote treatment. Hair-pulling scores were significantly lower in the active treatment group compared to the waitlist group, and over half of the active group saw clinically meaningful improvement in their symptoms. After all the participants received treatment, a combined analysis was done to observe change over time in both groups : of the 12 patients seeing clinically significant improvement at the final session, 7 of them kept their treatment gains 3 months after treatment ended. Psychological flexibility improved over the course of treatment and stayed stable until follow-up, but neither quality of life and shame showed demonstrable improvement over time. The nature of the telehealth treatment was well-received, with many participants confirming that remote treatment overcame many of the barriers they faced with conventional treatment, and demonstrating high levels of treatment satisfaction and therapeutic alliance. Improving the effectiveness of telepsychotherapy, which this study has highlighted to be a practical potential alternative to face-to-face treatment for trichotillomania, requires optimizing the technology and noting technical errors over the course of treatment, strengthening external validity by trying telepsychology with more diverse groups of individuals, and reassessing psychological variables like shame and quality of life with larger samples.

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