Monday, July 16, 2012

Habit Reversal Training: Why It May Harm More Than Help

Q. In working with the psychologist (and others in the past) I have encountered a lot of resistance to exercises such as recording/monitoring, delaying/exposure, habit reversal etc.  Do these exercises even have a place in the recovery process you describe? 

A. In this case I have to state that I am sharing my opinion.  Many who work with trich believe HRT is effective. A lesser number may use the recording/monitoring technique with TTM because it can be such an intermittent and unconscious process. My personal experience as a therapist and as a recovering puller is that most of these things are not helpful, although I do think things like delaying can help, simply to reinforce the idea that one CAN stop, even if only for a short time. 


First of all, HRT with trich employs the premise that the problem is keeping one's hands busy, or that TTM is about a need to fidget in some way.  I disagree with this entirely. Hair pulling or skin picking is known to create or occur in a trance-like state for most people.  The feeling is described as womb-like or cocoon like, probably due to the repetitive motion of the pulling and the chemical response of the brain to hairs being pulled**.  There really is an altered state that happens when one pulls that is generally recognized to soothe.  Like having a couple of drinks (or many more than a couple) after work for an alcoholic, hair pulling (or skin picking) for 20 minutes to an hour can noticeably change a puller's state of mind (although this is tampered with because of the guilt and shame that also follows pulling). Like alcoholism, TTM is thought to be genetic, to have a physiological basis.  Studies with rats indicate that mice with TTM have a particular gene that can predict the disorder and it's believed likely that this is true for humans. My own experience with pulling gave me this same sense. It seemed natural and automatic to pull, and although I had the usual ups and downs of childhood, I did not suffer abuse or trauma. 

It's natural to think on hearing that TTM is or may be genetic, oh no! If it's in my genes then I'll REALLY never be able to stop or it will require a medication.  Nope, not at all.  Consider alcoholism, which is a disease known to have a genetic basis for a large percentage of alcoholics.  That information spurred drug companies to do extensive research seeking a medicinal cure for alcoholism, a cure that many years later has never been found. However it is widely acknowledged that membership in AA, which stresses a process of being in "recovery" that extends far beyond avoiding alcohol, is the single most effective treatment for alcoholism.  Despite alcoholism being genetic in many cases, recovery comes in a deeper change which is perpetuated by ongoing support meetings with others in the same boat.  I propose the same is true for TTM. 

So back to that drinking example, imagine using habit reversal training to recover from drinking.  Imagine my saying to an alcoholic:  Here's the solution to your problem. Every time you want a drink pour yourself a diet Coke on the rocks.  You will have a glass in your hand, ice cubes to clink, something to sip on. Your hands will be busy, you will hear similar sounds with ice cubes, you will satisfy oral cravings by sipping on something.  Well of course that advice would be seen as ridiculous.  Simple reason: People who drink alcohol drink it for the altered state, they don't drink to keep their hands busy or satisfy thirst or oral cravings.  It's true that the process of drinking (pouring a drink, maybe on the rocks, enjoying the feel of the glass) may be so associated with the altered state alcohol creates, but in the end, it's not what people are after.  The same is true with TTM sufferers.  They may associate those busy hands with the longing for the altered state that occurs while pulling.  And for a short period of time, having their hands occupied may prevent pulling.  So maybe these hand toys have a temporary use, and can be helpful. But ultimately the addiction to the state of mind will return pullers to pulling just as it returns to alcoholics to drinking. 

So in summary, habit reversal training is missing the point. Pullers don't just need to keep their hands busy or have tactile stimulation. They long for the state of mind that pulling creates, and that's something that fist clenching and playing with Koosh balls cannot bring about.  And that's ultimately why HRT, in my view, doesn't work. 


As you see in an earlier post, I do recommend one kind of journaling. The writing down of a number at the end of each day from 0 to 10 to rate your pulling for the day, 0 being zero pulling 10 being your worst day. The purpose of this is crucial: Because your hair won't accurately reflect results of getting better, you must have some way to see that, hey, I'm getting better. You must have something you can refer to when you have a slip or bad day to remind you that, hey, today and yesterday may have been a 9, but the last two weeks I had more 2s and 3s than the previous two weeks, and overall I am pulling less. So I need to stick with this and not give up.  This is important.  

As to journaling every instance of pulling, something I tried myself when I was pulling, here is why I don't think that works. In my view, pulling daily or often reduces ones overall sensitivity to painful feelings. It isn't necessarily tit for tat, or, a bad feeling occurs and then I pull.  Sometimes this happens of course, but not all the time.  Pulling is known to be self-soothing behavior, but the soothing doesn't necessarily happen in IMMEDIATE response to a stressful event. Many people report that during high stress they don't pull excessively, but when that stress is over, that's when they pull.  Further, I see hair pulling as an addiction. One likes the altered state produced and becomes addicted to it. These cravings are progressive, as alcoholism as. And as in the case of alcohol, the effect lasts so long, and then wears off.  And when it wears off, the cravings begin again.  I propose this is not unlike urges to pull.  One begins to crave the feeling when the neurological effect of pulling has "worn off" or to keep one's mood and experience even and calm.  Hence one will often see people not in real recovery force themselves somehow to not pull for several days, and then suddenly we react and MUST pull lots and lots for two or three days in a row to get one's body and mind back to a certain state. 

The journaling exercise is bound to fail, I feel.  For most people some of the pulling is so brief there is no time or ability to record it, and no way to retrieve what one is feeling in exactly the moment preceding. Further, I believe most of the feelings a puller has that she or he is pulling to "numb out" are feelings she doesn't truly understand and thus cannot accurately record them.  In addition, TTM is characterized by overwhelming cravings to pull hair out and, like an addiction, to ignore the consequences in the moment of pulling. Like with any addiction, when we find ourselves doing it and the craving is strong we find any way possible to continue. We ignore becoming conscious or aware and stay in that half-aware state as long as possible, we rationalize that we "deserve to pull" right now because of X, or that we "don't care" if we are pulling (because if we let ourselves care it HURTS too much) or that it "doesn't matter" if we pull (because we've pulled so much hair out anyway, and it already "looks like shit.")  With all these profound and intense methods to deny what we are doing and not face the consequences in the moment, how is it possible that intense craving and internalized denial won't also stop us from doing the recording and journaling?  Of course it will.  We will rationalize doing it later, or that it doesn't matter, or there's no point, or it will feel hollow and pointless in comparison to overwhelming and consuming urge to pull.  Bottom line, we won't do it. And then we will have another failure on our hands. Another thing that fails, that does not work, that reinforces our belief that we will "never" be able to stop.  


In most cases, the only way any of these methods would work is if hair pulling is not addictive but voluntary.  In almost every case, people are pulling because they simply long to pull.  No need to write it down.  It's a longing, a craving, an addiction.  Would anyone ask a person to keep such detailed journals of their drinking or sex addiction? No, because it's understood.  Because the pleasure and the altered state involved in pulling is not at all obvious, some treatment providers may feel there needs to be an explanation as to why one is engaging in the behavior.  I think the behavior is addictive because it feels good (or soothes bad feelings at least) and we want that feeling. 


Whatever you've done or tried, if it helps or has helped, do it.  However if you are trying something and struggling, if HRT or journaling or any other such method causes such resistance that you continually feel you are failing at yet another attempt to recover from trich or skin picking, this I consider a serious problem.  Most hair pullers try to stop over and over again for years.  That's all they do is try to stop. They swear off pulling. They vow not to pull. They wear clothes. They put conditioner on their hair. They shave their heads, even. And when these things ultimately do not work, people with trich feel HOPELESS.  And hopelessness is the one surefire way NOT to be able to recover.  Self-hatred is another. That's why instilling some hope and some self acceptance are crucial to do before forcing one's self to do exercises that feel futile.  


I find that hair pullers and skin pickers, for the most part, share certain traits that pop psychology refers to as "codependence" but can also be thought of as an addiction to external validation.  They worry about what people think of them, whether they are being "nice," whether what they said or did was acceptable, and mostly, whether they are being selfish.  My experience is, hair pullers and skin pickers are not only NOT selfish, they need to be more selfish.  They are typically exhausted, at least mentally, because they put so many demands on themselves to be good enough (perfect) at work, as a friend, as a parent, as a partner, as a daughter or son. Pullers don't believe they deserve to be loved for who they are, but rather, for what they do and how well they do it.  This leaves them in a frequent state of exhaustion and despair, always preparing to be abandoned, rejected, fired, unloved, and humiliated. 

Some things that must be accomplished in the early stages of recovery include 

1) Understanding that TTM or Skin Picking is Not Your Fault. 
Until one lets go of the false belief that one "should" be able to stop, and that one is pathetic or weak because of one's inability to do so, it is impossible to stop.  This is a real disorder, and if will power allowed on to stop, most of you would already have done so.  Pullers are very motivated. To get to the place where you accept this generally requires education and/or support groups (online or RL) and/or working with therapist who is extremely familiar with trich and has worked with many many cases.  

2) Working on Self Acceptance
Reading Radical Acceptance by Tara Brach is an excellent start.  The goal is to begin to come to a place where one is able to accept one's self as a human being and not withdraw that acceptance or self love because one isn't perfect or makes a mistake. That means, coming to a place where one's self love is now withdrawn UNLESS ONE STOPS PULLING. Letting go of the conditional self love implied in this equation. So long as you hate yourself because you pull, being able to stop will be just out of reach. You need not be completely self accepting to stop pulling, only make progress on it. People fear that self-acceptance means being lackadaisical and apathetic.  Giving up. Just the opposite! As famed psychotherapist Carl Rogers once said: The curious paradox is that is only by accepting one's self that one is able to change. 

3) Understand Boundaries & Setting Them
Looking at one's relationship with friends and family and understanding what it means to set boundaries is huge for pullers and pickers. This means learning to say No, learning to set limits on your time and money, and understanding that if anyone in your life (even your mother) asks more of you than you are able to give or suggests that your relationship is contingent on you meeting their needs, you will have to rethink it. Chances are high that no one in your life will actually reject you or leave you because you've set boundaries, but if they will, you may as well find out now.  

4) Learning, Accepting and Believing the Gradual Improvement Model
As long as you look at recover from pulling as black and white, that either you stop completely 100% and don't pull again or you have failed, you will fail.  Recovery is gradual.  It can be no other way. It will be two steps forward, one step back, But you will move forward. Keeping the calendar with the daily rating on it will help to reinforce that you are getting better after you've had a bad day.  Without this understand and this approach, you will continue to feel you are failing, and you will give up. When you understand that this is not so, that slow and steady wins the race (the TORTOISE wins and the HARE :) loses).  

The above things are not easy but they will make your life so much better that despite you not believing me now, you will be more grateful for how you feel after making them then you will about no longer pulling.  Generally being in therapy is important, although lots of reading and online support groups (relating to codependence, for example) can also help.  You can make headway on these issues in several months to a year with a qualified therapist.  A therapist who works with food addiction may well be able to understand pulling and picking as there are similar things at work and a similar way to recover. The difference with other addictions is they must be stopped "cold turkey."  Food addictions don't work that way, and it's understood in recovery that there will be slips and bad days, and that one still progresses.  So if you can't find a therapist who deeply understands trich, you may far more easily find one who works with food addictions or process addictions (addiction to spending, gambling, sex). 

Just reading this blog means you are in recovery.  If you do one thing every day to support yourself in the journey to wellness and freedom from pulling, you are on your way.