Saturday, October 1, 2011

Change Your Thinking, Change Your Behavior

I have been sharing my view that hair pulling & skin picking are most like "addictions" for many years.  I was not taken seriously by other professionals at first, but in recent years I've seen the term used more and more when other professionals talk about Body-Focused Repetitive Disorder (BFRD).  In fact, TTM & Dermatillomaia fit the criteria of addiction quite well. Think about the way we respond to an addiction like substance abuse (food, drink, drugs). We develop a craving, we try to talk ourselves out of it by saying: You don't really want to drink again, you'll lose your job. Don't eat that whole box of cookies, you'll feel sick and diagusted. Don't keep pulling your hair out, there won't be any way to cover it up. 

The addict in you rebels against this kind of feedback. You want to do it, and all the consequences you are thinking about happen in the long term. You feel bad NOW. Gaining weight or losing hair happens later. You just want to feel better. So finally you  say, "Screw it. I don't care about the consequences," and we block out the fact that we missed work last time we drank, lost custody of our kids, took any number of actions that cause us shame, pain, financial loss or worse. You say, "I don't care, I had a bad day and I'm going to do it." Or "It doesn't matter, I already ruined my hair, I'm already almost bald, That is how we give yourselves permission to pick or pull. 

1) (Screw it.) It's hopeless.
2) I don't care
3) It doesn't matter anyway.

And by convincing ourselves for just a few minutes that those lies are true, we rebel against what we really want. We pretend that we "don't care" about pulling, that we've done so much damage it doesn't matter if we pull or not, and finally we feel so hopeless about the idea of stopping forever, we don't see the point in stopping NOW. (It's quite similar to the process of procrastination which is often connected to BFRD behaviors: Denial, Delay (now we've waited so long it will never get done), Hopelessness)

Rather than trying to "FORCE" yourself to stop, the key is to understand and change the pattern of addictive thoughts. It doesn't matter whether you are a picker who is aware that you are about to pick or a puller who has already pulled for ten minutes before you become aware of what you are doing. There will be a moment when you ARE aware of what you are doing and think to yourself: "I don't care!" This thought comes in response to earlier thoughts like, You "shouldn't" be doing this OR I can't believe I'm doing this again. We think "I don't care!" as a way to tell our inner bully to shut up, leave us alone & let us pull. Because let's face it, pulling & picking are made less pleasurable when we simultaneously are attempting to shame ourselves for engaging in the behaviors.  (And SHAME does not help one bit, of course.)  So we say to ourselves by way of making the shame stop: I DON'T CARE! (In other words, leave me alone, Bully, I want to pull!)

The problem is we have dis-identified with the real reason we want to stop these behaviors, which is not that they are morally wrong or that we "shouldn't" do them. Rather, it upsets us *THAT* we do them. And it is crucial to acknowledge that, but at the same time, not shame ourselves. 

Here's what I mean. See if you can become aware when you start to think to yourself: I don't care! Once you do, apply what Mindfulness practice teaches us is the "observer" within and "note" the thought. 

You: I don't care
The Observer (You): Ah, there's that addictive thought. Telling me I don't care. Giving me permission to pull. 

The problem is, you DO care. You care very much. If you didn't, you sure as heck wouldn't be reading this blog. You just want to forget that fact for a moment, an hour, two hours, so you can go to that familiar (and comforting) sense of "Numbness.".  So what I'm asking you to do here is this: DO NOT bully or shame yourself into stopping. (What are you DOING?! What's wrong with you?! You're "pathetic"!) But DO acknowledge that the behavior is causing you pain. The example I give to my clients is this: Imagine an alcoholic who is living in a one room apt. after having lost his (or her) share of custody with his kids. He has to get sober and stay sober for 6 mos to get the issue revisited. Six months seems like FOREVER. So every night, to numb the pain of not seeing his children, he pulls out a bottle of whisky. He may say, You moron, what are you doing? But he feels compelled to continue. So he takes the pictures of his kids and turns them around. Puts them away. It's too painful to look at his kids. He's already "blown it" he thinks. 

Now I would tell that guy, Go ahead and drink. But do NOT put away the pics of your kids. At the same time, you don't get to berate yourself for doing something you feel so compelled to do despite all it has cost you. What you do is this: You look at your kids and think to yourself, wow, this drinking has cost me a lot. And it's not because I don't care about my kids cause I do! How powerful this addiction must be if it makes me ignore what truly matters. Now this makes the drinking FAR less enjoyable & shifts this man's thinking from "I'm shit. I'm a loser." to "This is a serious problem & it's costing a lot." That latter voice we can call the "Supportive Friend." The friend you can be to yourself. The friend who wants to HELP you, not SHAME you.  It's a completely different way of relating to the self.

Here's how it translates for sufferers of TTM or Dermatillomania: 

Your Inner Bully (You): Stop pulling you pathetic loser! 
BFRB* Addict (You): I had a lousy day. I just don't CARE right now!
NEW-Observer (You): Ah, there's the inner addict trying to convince me I don't care.
NEW-Supportive Friend (You): You know what? That's not true. I DO care. I care very much.  It causes me  emotional pain to do this. It makes me feel bad about myself. I just want to acknowledge that. 

Now at this point, I am not saying that you can (or should) instantly stop. Not at all. I am suggesting that you go ahead and pull or pick, while simultaneously acknowledging that you DO care.   Not that you're an idiot or weak or pathetic. Rather, that you are a human being who's desire or urge to do this is so strong that it eclipses the fact that the behavior causes you so much pain. Now that's a HARD spot to be in, and until you can empathize with yourself, you remain stuck in a cycle of Blame, Shame, Addictive Thought, Numbness, More Shame, Emptiness, Self-Hatred. 

Please note that I am suggesting you tell yourself that you DO care, NOT because of hair loss or scarring but because you will feel bad about yourself. That's very important. We all know how long it takes for hair to grow back or skin to heal. It takes so long it's hard to feel motivated. That's why it is crucial you motivate yourself based on how you feel about yourself. That can become your immediate payoff. And when you consider the crippling shame and self-hatred that appears sometime after a pulling or picking session, perhaps you can see that there is another kind of cost to this besides hair loss and skin scars.  And when that can be replaced by actively telling yourself that you made an effort (even if the effort at first is just changing your thoughts), you will become a real support to yourself, a cheerleader, a caring friend and more able to continue on the path of recovery. A bully, a critic, a shaming, finger-wagging inner "bad parent" WILL NOT HELP YOU. That kind of thinking will tear down any efforts you make toward your goal. That kind of thinking SUPPORTS the addiction. And you do not deserve it, as one day you will surely know.

As I said for the "I don't care" thought, the same goes for "It doesn't matter," and "It's hopeless." The thought "It doesn't matter" is generally linked with the fact that you've done so much "damage" that it doesn't matter if you do a little more. It's the same irrational thinking behind, "I went off my diet and ate some cake! I 'ruined' everything. Well, I may as well eat everything in the house." Because that makes sense, right? You ate an extra 500 calories so you may as well eat 5,000. 

First of all, even when you break it down literally, I can tell you that it DOES matter. In the practical physical world, even though you may not see the difference right away, any lessened amount of pulling, (55 minutes and not an hour, 3 hours and not 4) is PROGRESS. And progress is what will help you reach your goal. But going back to my earlier point, it's about shifting the focus in this moment away from what your hair or skin looks like and acknowledging that the shame and anger toward the self you feel is hurtful. It not only doesn't help you pull less, it absolutely causes you to pull more. Please hear this: All attempts to attack, shame or SCARE you into less pulling or picking, whether done by you or someone else, do the OPPOSITE. Every "I can't believe you're doing that!" "Stop it, you're making a mess of your face!" "Why can't you.. STOP doing that??!!" and "What's WRONG with you!!" will push you FURTHER from your goal. Please stop and think about that. You don't want to "let yourself off the hook." You falsely believe that loving yourself or, yes, accepting yourself, even while you are still pulling means you are "giving up" and just accepting this is how it is. That's just plain wrong! Just like you love your kids even if you don't love the behavior, just like you accept them (vs. rejecting them) when they make mistakes, so too you must accept yourself. Accepting and loving yourself NO MATTER WHAT is the ONLY way you'll recover.

So you see, it does matter. New dialogue: 

Inner Bully (You): Stop pulling! Stop picking! You're pathetic.
BFRB* Addict (You): I've already messed up my hair (skin) so much it doesn't matter anyway.   
NEW- Observer (You): Ah, there's the addict trying to snow me into believing it doesn't matter.
NEW-Supportive Friend (You): You know what, it DOES matter. It matters because how you feel about yourself matters. It matters because  it's about small steps, and even if your skin or hair won't shift right away, it will eventually if you take those small steps. And it MATTERS because this pulling or picking makes you feel like shit, and recovery only happens a moment at a time.

That same point must be made when recovery feels hopeless. One can imagine that that's very much how someone who has 100 or more lbs to lose might feel. Because no matter what one does, change doesn't come overnight. Also, you cannot stop pulling "FOREVER" all at once. You can only improve a little in each moment. Those moments will add up, and believe me, they can become a total cessation of pulling or picking, or a nearly total cessation of pulling or picking over time. But any efforts you do make must be made for TODAY only. Forever feels too big. Forever feels hopeless. Today (or even "right now") need not feel hopeless. You will be able to DO today. And it's ok if you can't quite do that right now. 

Changing the dialogue is the first step. Working on self-acceptance and self-love, letting go of negative reinforcement and focusing on positive reinforcement, that must be done before any other efforts are made. 

And, NO, you won't have to fight the urges forever. If you change your thinking and change your relationship with yourself so you can support yourself and love yourself through the process, the urges will start to subside. Just like with any addiction, the urges and the desire takes time to subside, and once in a while may show up out of the blue. That's why you'll need that "Supportive Friend" with you. The part of you that encourages you and believes in you, just as you do for your friends who aren't you. Imagine if you could be as helpful to yourself as you are to others.     
With practice, you will see that making just a little progress on this (which is all you CAN do) will eventually get you where you want to go. Just like a person who needs to lose 100 lbs. Yes, they won't be where they want to be after a day or a week of progress toward healthy eating. But they will have taken a step. And it's one step, then another, then another, and then maybe a step or two back. That's how it goes. If you can find a way to accept that, if you can find a way to encourage yourself based on "progress not perfection" (AA), you CAN recover. If you continue to believe that it's all at once or nothing, Your inner addict wants you to believe this so you will give in and pull or pick. Your inner bully wants to tell you it's hopeless. But your inner Supportive Friend knows the truth. It's one day at a time, one moment at a time, one breath at a time. It's taking one small step and focusing only on what you can do, not what you cannot. THAT, I can tell you, is one of the most important things to know about the journey of recovery from BFRB*s. The second is, You CAN do it! 

*BFRB = Body-Focused Repetitive Behaviors  

Wednesday, September 28, 2011

The "Secret" to Recovering From Pulling and Skin Picking

Safely in the privacy of my office, after the usual pleasantries, most hair pullers and skin pickers lean forward and in a hushed tone ask, So, how do I stop pulling? What do I do?  My answer is this: No matter what method you use, you will have to do one crucial thing: You must completely change your relationship with your pulling or picking.  With almost no exceptions, pullers* have a bad child v. punishing adult relationship with their hair pulling You swear to stop & never do it again. Suddenly you are doing it again. Then the attacks begin:

What's wrong with you??!!
This is disgusting. I am disgusting.
Can you imagine what ___ would think if they knew?
It's ridiculous that I can't stop this silly habit.
I'm so ugly and awful.
No one will ever love me- and I don't deserve to be loved.

These attacks may continue at a subconscious level so that you are always feeling like a failure. You're a failure because you "should " be able to stop but you can't. You are filled with shame because you believe that your behavior is disgusting and pathetic and that if you had a shred of self-discipline you'd be able to stop. You fear people will find out, or that they may know, and you're sure they would be (or are) horrified. Because you wrongly believe they should be horrified.

All of this self-berating has to stop. It won't matter what technique you use or what therapy you try or what homeopathic formula you take or what hypnotherapist you see. Until you begin to understand on a deep level that Trich (or skin picking) is a disorder,  that if self-control was all it took, millions would not suffer from this, that your worth as a human being is NOT diminished by having this problem, that you are not pathetic or disgusting AND that you deserve self-compassion not contempt, you simply cannot recover from Trich or skin picking.

If you are thinking, How can it be a disorder if I "do it to myself", you still don't understand the nature of TTM and skin picking. Let me ask you this: Do you believe anorexia and bulimia are real problems? If so, how do they differ when it comes to the idea that they are self-inflicted so don't count. And two, are you aware that you are responding to an urge, whether physical or psychological, when you pick or pull? If so, where do you think that urge comes from? That's the disorder!

So what does it take to find the kind of self-acceptance and self-compassion to be able to embark on your own recovery? The answer is: THAT is the work.  Recovery is not "forcing yourself to stop pulling." It's shifting the way you feel about yourself.

Reading a book called Radical Acceptance by Tara Brach may help toward this goal. Attending TLC ( conferences and retreats may help because once you meet others with Trich & truly see they are not gross or disgusting or horrid it's easier to consider that you are not either. Therapy, even CBT therapy, would be best used for this purpose before launching into practices like habit reversal training,  journaling, record keeping, affirmations and relaxation exercises. Any attempts to stop pulling, if punctuated by a stream of cruel, mean, judgmental thoughts, will fail. It's as if you have a bully living inside you. This bully has no patience for being imperfect. This bully will convince you that even if you do have four good days and one bad day, that that bad day means you are a failure and you'll "never be able to stop." And when you consider the fact that recovery generally is two steps forward, one step back, that four good days out of five may be may be the best you've done in a long while, and that that fifth day (one step back) is an inevitable part of recovery, perhaps you can see that taunting and demeaning yourself for the very process that IS recovery will be the very thing that prevents recovery. I tell my clients, when you get to the point that you can have four good days and one bad day, and on that bad day acknowledge that, while you may feel bummed out or disappointed, you actually are doing really well and there's no reason that tomorrow can't be a good or better day, well THAT'S recovery.

If on that proverbial 5th bad day (maybe its a 5th hour, maybe a 5th bad week) you attack yourself, you tell yourself that SEE, that proves I can't recover, look, I failed again, that bully will have successfully undermined real success. And if you don't support yourself through the process (even that 5th bad day is part of the process) and if you undermine real success (any improvement is success and tolerating the "one step back" and continuing to encourage yourself after a bad day is a HUGE part of success) then your inner bully will win and you won't get where you want to be.

Until you can honestly say that you love yourself EVEN if you are pulling  just like you would continue to love your child, best friend, spouse or anyone else you loved EVEN IF THEY HAD TTM or skin picking issues (and would feel compassion for them not disgust), attempts to succeed are highly unlikely to work. 

Most pullers have conditional self-love. They love themselves if they don't pull.  And if all support, worth, compassion and kindness is withdrawn unless you have a complete and total cessation of pulling instantly, you remain in a dynamic with yourself that is CAUSING you to fail.  If, on the other hand, you can love yourself whether or not you are pulling, recovery, no matter what method you use, will be far easier than it presently is.  In other words, you have to love the puller not the pulling. Then you're on your way!

Thursday, June 16, 2011

Great News! FINALLY! An Amino Acid Proven to Help Hair Pullers (Skin Pickers too)

Let me say first, thanks to Dr. Jon Grant, there is something you can start taking immediately that will very likely reduce your hair pulling*. Not only that, it's good for your health! I've helped people reduce or cease their hair pulling without any supplementation or meds, but NAC may well substantially reduce the amount of time it takes and improve the results one gets. I'll give you specific info on dosing and a link to the study and to a video of Dr. Grant discussing the study, below. (*Dr. Grant says skin pickers very likely will be helped too, and has seen this, but this study was focused on hair pulling. More research is being done on NAC and skin picking but it looks good.

As truly exciting as the NAC study is, it is crucial to understand IT IS NOT A MAGIC BULLET (though it will help!) My experience suggests that there are several things that must be addressed in order to truly recover from hair pulling and skin picking, but to have the physical urge reduced will make it substantially easier to recover. These areas (which I will outline in detail in future posts) are 1) Mindfulness (learning how to notice the kinds of thoughts that affect mood, self esteem and procrastination); 2) Learning to identify "addictive" thoughts just beneath conscious awareness in which you give yourself "permission" to pull or pick (even while more conscious thoughts appear to be, "don't pull," and "don't
pick"; and 3) Understanding the role "Perfectionism" (and its flip side, procrastination) plays in the psychological desire to pull or pick.

Until very recently, there has been no drug or supplement that has been proven to significantly help hair pullers reduce their behavior. Researcher Jon Grant, MD, JD, MPH, of the University of Minnesota, Department of Psychiatry, who ithin the Science Advisory Board of the Trichotillomania Learning Center (TLC) has changed all that. There finally is something hair pullers can take to make it far easier to reduce hair pulling behavior.

The results of Grant's study, published in the July 2009 issue of the Archives of General Psychiatry, are quite promising. In a double blind study, 56% of subjects who took at least 2400 mg a day of NAC (four 600-mg capsules) for at least nine weeks saw a *significant*
reduction in hair pulling compared to 16% of subjects who took a placebo. No antidepressant or
any other substance has has results like these. Dr. Grant had initially thought one might get results with 1200 mg a day, however he has since revised that opinion and believes 2400 to 3600 mg is needed. So if you tried NAC at 1200 mg and nothing happened, that doesn't mean it won't. Grant says levels of NAC of up to 3600 mg are safe (and the supplement also has been
shown to strengthen the immune system and helps prevent liver damage from substances like Tylenol and other OTC drugs.) So it's not just safe, it's good for you.

Dr. Grant suggests that you take NAC as follows: 600mg am* and 600mg pm* for two weeks WITH Vitamin C. 1200mg am and 1200mg pm for two weeks WITH Vitamin C. You may then go up to 1800mg am and 1800mg pm with Vitamin C and in one more week go up to 2400mg. Dr. Grant says that 3600mg is safe and may be necessary. I have my clients go up to 3600mg, 1800mg in the am, 1800 in the pm.

The study suggests that it is VERY important to take Vitamin C daily with NAC. Dr. Grant says you may need 2-3 times the daily recommended requirement of vitamin C (and possibly zinc &
copper) when taking NAC long term. He recommends a Vitamin C complex tab daily. Taking one 1000+ mg a day should be sufficient.

Although you can buy N-Acetyl Cysteine (NAC) at most vitamin stores or Whole Foods, and it isn't especially expensive, since you'll need 4 to 6 pills (600mg) a day, it's important to get the best possible price. (You can buy a bottle of 60 600-mg tabs for about $10 at Whole Foods if you want to get started. However sells 100 600mg tablets for under $6.89 (It's an amino acid- it's all the same stuff.) At that price, it costs about $7.50 for a month supply at 4 a day (2400) and about $13 a month if you take 6 a day (3600), which most adults need.

Here is a link to the abstract:

More info on if you put in NAC in the search engine.

Sunday, May 8, 2011

Now What? Life Beyond Self-Soothing

It's no wonder people engage in self-soothing behaviors in this crazy world of ours. It's not easy to remain centered with the economy crumbling, earthquakes and tsunamis wreaking havoc and goverments falling apart. It doesn't matter if these things affect you directly; in fact, it's more the slow but sure external chaos created as a result of these events, moving out in wider and wider concentric circles. It's futile to wait for external order to happen. But no matter what you experience, if you can read this, you can practice bringing that ease you long for to your inner life.

For hair pullers, right now, this very instant, decide to love yourself NOW. Not when you stop pulling. I guarantee -- you have this in writing -- that most people will NOT judge you or think less of you cause you draw on eyebrows or wear a wig. You are trapped in an illusory world that you've created, a world where you are judged, a world in which you are "not good enough," and one filled with people who will abandon you.

But to all of you who feel that way I can honestly say this: You are not who you think you are! We all construct a reality when we are very small that is our way of perceiving the world. If our parents ignored us, we will learn that we are not worth paying attention to. If they told us we weren't good enough, even with the intention of helping us to be better, the lesson that sticks will be, we are not good enough.

And as we walk through our lives with a virtual sign on our head thst says "not good enough," or "not worth much," or "will be abandoned," well guess what? We are carrying our faulty beliefs into the world we inhabit and our behavior, our body language, our choice of words, all these will convey these beliefs to those we meet.

How can I stop doing that, you ask? Well, in short, by truly observing and seeing and recognizing that this is what you are doing. That's the part that takes time. Asking yourself before you see friends, meet someone new, take a walk, even, What beliefs am I bringing with me? If you're nervous about people liking you, that may be one indication that you don't believe you're likable. It's ok to be nervous. But ask yourself, Would you be nervous about whether people will like your best friend or your dog? Probably not, because you know they're great. You know they aren't perfect of course. But if people don't like them I'm sure you would believe it was THEM, not an indication that your friend and dog are not likable or good enough.

So step one, ask yourselves what beliefs you are bringing into each situation and see if you can identify them. You don't need to try not to feel scared or insecure. Just identify the beliefs. And label them. Ok, im scared because I believe people will think I'm dull, silly, not smart enough. Those are beliefs. And even though they feel like "reality" because I've looked at things this way as long as i can recall, I can see that this is not reality. If you can't say that, just see if you can say to yourself, I can't quite see that my perception is not reality. But I'm willing to.

As a therapist, I too once valued and prioritized how I felt over what I think. I would say, Well this is how I feel! I would defend to the death my right to be miserable. And I do have that right. I'm just not sure I want it.

So how will the practice of observing what beliefs I carry change things for me? Well, doing it just once will not. Doing so regularly though will. Because you will begin experiencing yourself as a being separate from these beliefs. And eventually you will actual feel different.

Two short books may help you to see this is true: Freedom from the Known by Krishnamurti and The Miracle of Mindfulness by Thich Nhat Hanh. Krishnamurti will help you to see how your perception of Self has been created by who you think you are and who you believe others are. Once I read it I understood how much more there was to me and everyone I knew. Thich Nhat Hanh's book will give practical instruction in observing your thoughts and beliefs.