Evidence Based Treatment and BFRBs: What It Is and Why It Matters

Dr. Dawn Ferrara
Apr 26th, 2021

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They say for every problem, there’s a solution. Well, that might be true, but it depends on how you define the solution. When you’re looking for answers to a problem, there’s no shortage of recommendations, stories, and downright fantastical tales of overnight cures. A quick spin around the internet will yield thousands of promises, cures, and magical treatments all promising relief for BFRBs like hairpulling and skin picking. Some of them even sound plausible. It’s tempting to latch on to whatever “sounds” good. The problem is, how do you know if it actually is helpful?

If you struggle with a BFRB, you’ve no doubt done your share of searching for relief. In your search for treatment, you’ve probably come across the term “evidence-based treatment” or EBT. It sounds good, right? But what does “evidence-based” really mean? More importantly, what does EBT mean for people living with BFRBs?

The answers lie in science.

Defining Evidence-Based Treatment

The term evidence-based treatment refers to approaches to treatment that are based on scientific research and facts. Evidence-based treatment has been extensively researched and found to be effective in treating the intended problem. This knowledge of sound, best practices can then be used to guide clinical decision-making and treatment planning.

What might surprise you is that EBT is not a new concept. While the term “evidence-based” is relatively new, the concept of EFT goes back centuries with its roots firmly planted in medicine. Beginning with ancient era journals and anecdotal accounts, to textbooks, empirical studies, and peer-reviewed journals, to today’s databases and software, EBT is now considered a best practice in patient care across disciplines.

Why Evidence-Based Matters

When it comes to treatment, evidence matters. History is full of things that were touted as “treatments” and “cures” but later found to be at best ineffective and at worst, dangerous. And, you could always find someone for whom it brought relief. But, there were just as many people who found little or no relief, or worse, were harmed. The problem was, there was data, or information, but no evidence to support the treatment. It was mostly trial and error with people hoping for the best.

To be sure, many of the treatments we enjoy today had their foundations in folk medicine or people just trying things and stumbling on something that worked. Or maybe worked sometimes. Or did it really work at all? There were probably a lot of epic fails and frustrations too. Sometimes, even those things that tend to not work so well stick around despite their lack of effectiveness. Opinion-bias tends to focus only on the “successes” – it seems to work so it must be true. People stay stuck and don’t get better, but they keep trying.  This is why evidence matters so much. To truly know if something does what it says it does, you have to look for evidence not just stories.  

Random, unfiltered data and evidence are not the same. Evidence requires that data be gathered and analyzed using specific, standards of scientific practice. Scientific evaluation provides objective information about how well something works, how it works, and for whom it might work best. Science can also tell us when something is at best ineffective or at worst, dangerous. In short, something that is evidence-based does what it says it does.

A 2017 review of EBTs found that EBTs are more than just good science.

  • EBTs give patients an alternative to medication which many people prefer.
  • EBTs give clinicians a consistent framework from which they can develop treatment plans that are based on their patient’s individual needs.
  • EBTs tend to be safe and cost-effective.
  • EBTs are associated with a higher quality of care

EBTs and BFRB Treatment

The focus on EBTs has increased dramatically over the years and today, EBTs are considered best practice for clinicians. Not surprisingly, as the research into BFRBs has gained momentum, EBTs have found their place in the treatment of BFRBs.

Two of the most well-known and well-researched of these treatments are Habit Reversal Therapy (HRT) and Comprehensive Behavioral Therapy (Com-B). These approaches have proven to be quite effective. Current research is looking at how adding elements of other evidence-based treatments such as Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT) may enhance the effectiveness of these mainstay treatments. More effective treatments mean more positive outcomes and improved quality of life for people living with BFRBs.

EBTs are not only about treatment interventions. EBTs rely on accurate assessment. Part of the treatment process is the assessment of the problem using reliable and valid assessment instruments. A 2012 study examined the assessment tools used to assess BFRBs. Surprisingly, they found a scarcity of well-established assessment tools specific to the assessment of BFRBs, especially for children and adolescents. The researchers recommended the development of evidence-based assessment instruments, especially for youth. More accurate assessment can translate to more effective treatment interventions and outcomes.

An important thing to know is that EBT doesn’t necessarily exclude other treatment tools and processes. It is a framework – a tool in the toolbox. In fact, part of what makes therapy effective is the dynamic that is established between a client and clinician. There is certainly a place for more traditional talk therapy in the treatment process. You may even consider medication if needed.

BFRBs are highly heterogeneous. People experience them in different ways. Part of the foundation of EBT is the respect and awareness of patient preferences, values, and needs. EBTs offer a framework that the clinician can use to build a treatment plan that makes sense for the patient and their experience.

There is presently no single, one-size-fits-all treatment for BFRBs. EBTs offer the best in what is currently known about treating BFRBs. EBT offers ethical, science-driven treatment along with the flexibility to adjust for individual needs. It’s not a magical cure but a science-backed, flexible way to approach treatment. At the end of the day, the right treatment is the one that is right for you.


1. Claridge, J. A., & Fabian, T. C. (2005). History and development of evidence-based medicine. World journal of surgery29(5), 547–553. https://doi.org/10.1007/s00268-005-7910-1

2. Cook, S. C., Schwartz, A. C., & Kaslow, N. J. (2017). Evidence-Based Psychotherapy: Advantages and Challenges. Neurotherapeutics: the journal of the American Society for Experimental NeuroTherapeutics14(3), 537–545. https://doi.org/10.1007/s13311-017-0549-4

3. Skurya, J., Jafferany, M., & Everett, G. J. (2020). Habit reversal therapy in the management of body-focused repetitive behavior disorders. Dermatologic Therapy, 33(6). doi:10.1111/dth.13811

4. Falkenstein, M. J., Mouton-Odum, S., Mansueto, C. S., Golomb, R. G., & Haaga, D. A. F. (2016). Comprehensive Behavioral Treatment of Trichotillomania: A Treatment Development Study. Behavior Modification, 40(3), 414–438. http://dx.doi.org/10.1177/0145445515616369

5. Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C., Falkenstein, M., Heekin, M., … Jenike, M. A. (2010). Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depression and Anxiety27(10), 953-959. doi:10.1002/da.20732

6. Capriotti, M. R., Ely, L. J., Snorrason, I., & Woods, D. W. (2015). Acceptance-enhanced behavior therapy for excoriation (skin-picking) disorder in adults: A clinical case series. Cognitive and Behavioral Practice22(2), 230-239. doi:10.1016/j.cbpra.2014.01.008

7. McGuire, J. F., Kugler, B. B., Park, J. M., Horng, B., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2012). Evidence-based assessment of compulsive skin picking, chronic tic disorders and trichotillomania in children. Child psychiatry and human development43(6), 855–883. https://doi.org/10.1007/s10578-012-0300-7

Dr. Dawn Ferrara


With over 25 years of clinical practice, Dawn brings experience, education and a passion for educating others about mental health issues to her writing. She holds a Master’s Degree in Marriage and Family Counseling, a Doctorate in Psychology and is a Board-Certified Telemental Health Provider. Practicing as a Licensed Professional Counselor and Licensed Marriage and Family Therapist, Dawn worked with teens and adults, specializing in anxiety disorders, work-life issues, and family therapy. Living in Hurricane Alley, she also has a special interest and training in disaster and critical incident response. She now writes full-time, exclusively in the mental health area, and provides consulting services for other mental health professionals. When she’s not working, you’ll find her in the gym or walking her Black Lab, Riley.

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