(PS2-77) Homework Compliance Predicts Treatment Outcome in Acceptance-enhanced Behavior Therapy for Trichotillomania

Introduction: Between-session homework is a key component of cognitive and behavioral therapies and is associated with positive outcomes for a range of disorders. However, the role of homework in the treatment of trichotillomania is understudied. Thus, the present study investigated the connection between homework compliance in acceptance-enhanced behavior therapy (AEBT) for trichotillomania and therapeutic outcomes. We also tested potential moderators influencing the relationship between homework compliance and treatment outcomes. 

Methods: Participants included 35 adults with trichotillomania who received 10 sessions of AEBT across 12 weeks as part of a randomized controlled trial. Participants were predominately female (91.4%) and White (77.1%; 17.1% Black; 5.7% not reported). Participants’ educational backgrounds ranged from partial high school to graduate/professional school. Therapists rated homework compliance after each therapy session. Trichotillomania symptom severity was assessed post-treatment and at 6-month follow-up using the self-report MGH-HS and the interviewer-administered NIMH-TSS.  

Results: Higher homework compliance predicted lower trichotillomania symptom severity immediately after treatment (MGH-HS: B=-4.73, p=.043; NIMH-TSS: B=-3.79, p=.036) and 6 months later (NIMH-TSS: B=-6.10, p=.046). Homework compliance in later therapy sessions was a more robust predictor of post-treatment symptom severity (MGH-HS: B=-5.73, p=.027; NIMH-TSS: B=-5.30, p=.007) outcomes than early compliance (ps >.05). The association between homework compliance and treatment outcomes was stronger when the therapeutic relationship was rated as higher quality (B=-27.16, p=.010) and when patients had higher levels of automatic pulling (B=-0.78, p=.044).

Conclusion: These findings underscore the importance of between-session homework in trichotillomania treatment. Completing therapy homework may increase patients’ self-efficacy, promote habit formation, and generalize in-session learning to everyday life. Additionally, results showed that a strong therapist-patient alliance and higher automatic pulling moderated the effects of homework compliance on treatment outcomes. Our findings have important clinical implications and may encourage therapists to put more focus on building a strong positive relationship with patients and proactively address homework noncompliance. It may also be valuable to assess levels of automatic/focused pulling at the onset of treatment. Overall, efforts to increase homework compliance could enhance the efficacy of AEBT and lead to greater improvements for adults with trichotillomania, maximizing treatment gains and minimizing relapse.