Don't Try to Stop Pulling or Picking Before You Do This

After nearly 20 years of working with people who suffer from BFRBs and 20+ years of recovery from Trich myself I feel qualified to say that most people approach recovery from these disorders all wrong. Here is why: most people think that if they could stop here pulling her skin picking their life would work. Most people think that having a BSRB is their only problem. There are experts that will tell you that this behavior is simply an anomaly and is not indicative of any other issue at all. I must respectfully disagree. The good news is that having a BFRB does not indicate any kind of serious psychological condition but rather is a self Susan behavior. And I believe strongly that the need for this kind of soothing is related to certain types of issues. this is based on having worked with hundreds of people who have these disorders, and in nearly every case finding that addressing the issues of codependence, perfectionism, shame, and self acceptance have been the only and the primary way to guide my clients into a state of either pull/pick-free or mostly pull/pick-free recovery. The reason is that it's simply not possible to recover as long as your self-love and self-acceptance is conditional and based upon whether or not you pulled or picked that day

Every time I say that new clients say to me, but I don't want to accept the picking! I hate the pulley. I cannot accept it. And I say, first of all, when I am talking about is self acceptance. I am talking about excepting oneself as one is in this moment. I am talking about loving oneself as one is in this moment. If you had a child who had a problem, any problem, that they were trying to come back you would not withhold your love for your child until they had solved that problem. You might not love the problem but you would love your child and you would love him as he is. You would also accept your child. You would accept him exactly as he is now even if you continued to encourage him and support him in his quest to overcome this problem.

Here's the other thing. Acceptance is not in any way the same thing as resignation. Accepting where you are now does not mean you are resigned to staying where you are now. First of all that isn't even possible (or desirable) since we grow and change and evolve as people throughout our lives. Say I have a client who weighs 300 pounds. And let's say this clients doctor has told her that she must lose weight and that it is crucial for her health and her lifespan. I would tell this client also that the only way to succeed is to start out by accepting herself as she is now. at the same time this client may be on weight watchers, May be walking every day for an hour, may be incorporating a variety of new behaviors into her life. However weight loss is relatively slow and it may take a year before this woman can see in the mirror what she would like to see. However in order to succeed on this journey she must begin to see that this excess weight, while it is frustrating and while it is something that she wants to do something about does not mean that she is unworthy or a lovable or a bad person. she must learn to cease saying things to herself in her head like you're fat and disgusting and horrible. Because each time she does or says something like that to herself she begins to identify her worth as a human being with her excesss weight and she begins to reinforce the fact that she isn't worthy and she isn't good enough and if she isn't those things how can she possibly summon the strength to face this challenge? If she is only worthy and lovable and acceptable and worthwhile if she is thin, how can she possibly take on the work both emotional and food-related that is required to recover from food addiction and emotional eating?

In order to begin the journey to address a disorder like hair pulling more skin picking (or overeating), One must be prepared to face some uncomfortable feelings, because these behaviors numb feelings. One must be prepared to begin to set boundaries with people in their lives and take care of themselves, which in some cases may mean people will be disappointed. in order to do these things one most value and accept oneself, and One must even learn to let go of concern about the opinion of others. this is truly possible to do but it's only possible if you do the work needed to begin to love yourself exactly as you are now, with or without hair, with or without good skin. These things can improve greatly for you over time, but you have to start by loving yourself as you are now.

I believe BFRBs are inextricably tied to perfectionism, codependence, insecurity/lack of self acceptance, Constant worry about what other people think of you or at least what certain people think of you. And what happens when you slowly reduce the amount of pulling or picking that you do is that you begin to feel more. And you begin to feel many of the feelings that are the very feelings that cause you to engage in codependent and perfectionistic behaviors. this is why I work with people on learning to be in the moment with their feelings and to allow rather than resist painful feelings. When my clients start to realize they won't fall apart if they feel sad or scared or hurt, they become more prepared for the process of recovery. When my clients learn that even if someone disapproves of them, or even, gasp, if they fail at something, they are still OK and worthy and lovable, it becomes possible to let go of hair pulling and skin picking.

So if you're dealing with these issues and haven't had any luck at all with having these behavior subside, I strongly suggest that you work on self acceptance and self-love. As long as you hate yourself for having a disorder that you can't help having, trying to work on it becomes impossible. I have a lot more to say on the subject but I wanted to post something soon since it's been a while. I think it's so incredibly important to understand that without self acceptance and self-love as you are now the possibility of long-term recovery doesn't exist. If by some chance hypnosis or cognitive behavioral therapy helps you in the short term, in the long term it won't work because in the long term you have to have the ability to tolerate feelings and to set boundaries and to except yourself in order to remain in recovery.

I

Recovery from Trichotillomania / Hair Pulling

As a psychotherapist who's worked with hundreds of hair pullers, and as someone who personally suffered from daily hair pulling until I was 27 and has been pull free for 20 years, I know all too well the pain, shame and despair that pullers experience. I also know firsthand the frustration and hopelessness of trying *everything* to stop with no success. Or worse, having short-lived success--a day, a week, maybe even a month--and suddenly without warning you find yourself pulling again.

Maybe you pull your head hair, or your brows or lashes, or other body hair. My clients tend to be equally divided in that nearly half pull head hair and nearly half pull brows and/or lashes, a small number pull both, and the remainder pull from various areas on the body.

For those who don't have Trich, also known as a "body focused repetitive disorder" (BFRD, and don't understand it, but are close to someone who does, their own frustration and sadness about their child's, friend's, sibling's or partner's suffering may lead them to make constant suggestions (have you tried __ or ___), say to you, "Stop pulling, Honey," if they see you do it, or try to "convince" you to stop by "reminding" you: "But Honey you have such pretty
hair.." "You don't want to be bald, do you?" "Remember how upset you were about your lashes when you went to that dinner party, school dance, work, saw yourself in a picture, your friend asked you about it?"

As if you don't already more desperately want to stop than anyone else could ever imagine. What's hard to explain even to yourself is why you keep doing it, or why you do it at all. Why stopping seems so impossible when the behavior itself makes no sense. It just seems "crazy" or "gross" or you may feel "weak" and "pathetic".

What others don't know, and what you may not know, is that for people with Trich, hair pulling is a self-soothing mechanism (not an attempt to cause harm to yourself), and it feels pleasurable. It's not an addiction to pain. The other even more important thing is that you are being prompted to pull by a physical urge that can best be compared to an itch. When people have an itch, they tend to respond to it without thinking or even being aware they are doing so. That's why, if you have poison oak or chicken pox, you may not want to scratch, the doc may even say not to scratch, but the moment your attention is diverted (you're watching TV or you're on the phone), you "find yourself scratching." And at that point, the need to "complete or finish" scratching is extremely compelling, even if you don't want to. This comparison may help your spouse or parent or even you yourself to understand a little better what it is that causes you to start pulling in any particular moment. Either a physical or neurological urge occurs in a split second, as if you had an itch, and without conscious awareness you respond automatically. That's why you may not have any idea of a precipitating factor.

Now, if it were that simple, it might well be easier to treat. But it's important for pullers and their families to understand that this is not a willful behavior. Most people know what it's like to respond to an itch and begin scratching, sometimes for a minute or more, before you realize what you're doing. And most people also understand that, once you start scratching, poison oak for example, the craving to do so can overtake you, even though you know you shouldn't. Most folks also know that, when at its itchiest, you may find yourself scratching, stop doing so, tell yourself, OK, I'm not going to scratch anymore, go back to
your movie, and find yourself scratching again and again. Imagine if this urge was daily and constant. Imagine if it resulted in hair loss. Yet no matter what you did, you would suddenly and repeatedly "find" yourself doing it. That's, in short, what is happening to pullers. And because it as relieving to someone with Trich as it is for anyone to scratch an itch, you continue the behavior even when you're aware. It is extremely important to understand that you (the puller) are not "crazy." And anyone who experienced these urges, which occur in a microseconds, would respond the same way.

There are however, two other factors that come into play. I believe these urges have a cause that goes beyond that physical urge, and that are psyche comes to play a part in the constancy and intensity of these urges. Most people describe hair pulling as occurring in or even causing a "trance-like" state. This trance-like state kind of numbs one out emotionally, just like using a substance of some kind and also much like eating excessive amounts of carbs and sugar. This is why lots of people who have issues with weight may be engaging in what is called "emotional eating." One may crave carbs and sugar in a way that feels like "regular" hunger. You may feel like you have to have a muffin or donut or cookie or hunk of sourdough bread. Yet underneath that craving, outside your present awareness, it may be fear or loneliness or shame that in a sense causes those cravings to happen. And once fulfilled, the emptiness or loneliness or shame is covered up.. Numbed out. So people tend to think that "their only problem is overeating." Otherwise everything is fine. And this is exactly the same for hair pullers. The act of pulling numbs the longing or dis-ease, so it's easy to believe that if I could just stop pulling, everything would be fine.

I work with people to get beneath this fallacy, generally dealing with issues like perfectionism, a lack of self love and self acceptance, or rather, a self-acceptance that is conditional. If they make a mistake, don't finish their endless to do lists, aren't thin enough, productive enough, accomplished enough or smart enough (which they rarely if ever think they are), they see themselves as unworthy, "lazy," weak or just not good enough- And self love or acceptance is undeserved. That's why many clients I see who have Trich and who generally also have this overly harsh, critical, perfectionistic attitude toward themselves tend to seek external validation since they are unable to give it to themselves. And this causes a pattern of people pleasing behaviors that also lead to living an inauthentic life, a life where one is not true to one's self (since others' opinions of their lives tend to be more important than their own.

Once my clients are able to access some of the painful feelings beneath the urges, and begin to experience greater self-acceptance and self love, two things happen: They begin to lead lives that are more authentic and true to themselves, and their urges to pull begin to diminish. And using mindfulness and learning to embrace gradual reduction rather than instant total cessation of pulling, they are able to slowly let go of some, most or all of tbeir hair pulling.

Therapy Groups for Adults and Teens with Trichotillomania (Hair Pulling Disorder) in Los Angeles

Therapy Groups in Los Angeles for Adults and Teens with TRICHOTILLOMANIA (HAIR PULLING DISORDER) and Skin Picking Disorder. Pico-Robertson Area

Nine-Week Therapy Groups (which may become ongoing) for adults (and separate groups for teens) who suffer from hair-pulling or skin-picking. Groups led by Claudia Miles, LMFT who has 17 years experience working with this OCD-related disorder. In Pico Robertson area. Group will help members learn how to effectively address these disorders and feel hopeful again. Recovery happens!  Los Angeles. $60/group 

Contact Claudia Miles, LMFT at ClaudiaMilesMFT@gmail.com 

415-460-9737

www.claudiamiles.com

HelpForHairPullers.blogspot.com 

A Foolproof Plan For Recovery from Trich and Skin Picking

Whether you want to stop picking or hair pulling one thing will stop you from recovery: not understanding and accepting the gradual nature of recovery.  The pattern generally goes like this: you suppress the urge to pull* (pull or pick) for an hour, a day, maybe a week or more. You are happy about it. Briefly hopeful.  Then you find yourself pulling again, or suddenly feel unable not to give in to the urge. Then you may check the mirror, see a bald spot or scabs on your skin, believe you "undid" your progress and decide it's hopeless. What's the point of trying? 

Let me explain why that will NEVER work. You will not go from being an active puller to being completely pull-free in one fell swoop. The nature of these disorders is such that as much as you consciously want to stop, there is a part of you that does not want to stop because you get emotional soothing from the behavior. Further your body has some dependence on the behavior.  And while that doesn't mean you can't stop pulling or picking, it does mean there will be some resistance. And what THAT means is that recovery looks like this: you'll have good days followed by some bad days, then more good days followed by less bad days, until you eventually have nearly all good days and almost no bad days.

In order to note good days and bad days, you'll need to rate each day with one number. No extensive journaling or record keeping, but one number a day.  The pulling / picking scale I have devised is similar to the pain scale that you may be asked about at the doctor.  You rate each day from 0 to 10.  Zero means zero pulling, and 10 means YOUR worst day (use the last year as a way to measure your worst day). This is a subjective rating and does NOT have to be exact.  You will know the difference between an 8 on the scale and a 2 once you start doing this.   

Here is the thing about good days: They aren't zero pulling days, they are lower number days.  Depending on what your average pulling or picking day is, the days you actually pull or pick if you don't do it daily, you will choose a number that is not lower than 3, and that is within your reach right now, to be a good day. If you get lots of 5s and 6s, a few 3s and 4s, and a few 8s through 10s, pick 4 and below as your good day. If on the days you pull or pick you get mostly 8s, 9s and 10s, and a few 6s or 7s, use 7 and below as a good day.  If you get mostly 4s, 5s and 6s, a few 8s and 9s, a fews 3s, 2s and 1s, use 3 and below as your "good day."  For many people 3 or 4 will be your good day. But again, if that is currently out of your reach and you never get 3s or 4s, then choose a 7 by all means.

The important thing is that what you consider a good day is a) not lower than 3, and b) not out of your reach right now.

You might keep a record of these numbers on your electronic calendar or on a paper calendar that you can make. But every day that is "Good" (a number you choose like 3, 4 or 5 or below)  make a big X on that day. That's a recovery day. The idea is that each month you will have more and more of these good days. Once that is easy, you can lower the number you use for your good day, and work toward a slightly lower number.  Your goal always and only is to lower your  numbers each month, NOT to have your hair back or your skin looking great.  So long as your goal is focused on the results not the journey, you will get discouraged and give up.

So shift your goal from "having my hair back" or "having my skin clear" to collecting 30 good days, then 60 good days, then 90 good days, but NOT sequentially. That's right.  NOT sequentially. That means you can still have some very bad days.  See if you can get 30 good days in a total of 60 days. (If you get 30 good days in 75 days, that's great; now try again to get 30 good days in 60 total days. Once you achieve that, work toward 30 good days in 45 days. Keep counting the good days even if you reach 45 and don't have the 30 good days.  See how many days it takes.  If it takes 50 or 60, great. Try again for the 30 days in 45 days.  

If this is not going well for you, do NOT panic. That only means you must shift your goal. The most important thing here is to find a small goal you can achieve. If that means your good days are a higher number and in a larger total number of days, that's fine.  When you get there, see if you can improve it just a little the next time. If you do this, you will succeed. However, remember this: If you are someone like most pullers and pickers who a) cannot set boundaries (no Mom, I don't want your opinion) or say no to people easily; b) who is a workaholic and perfectionist; c) has constant self criticism running through your head or d) who does not take time for yourself; or have any other issue that is troubling you including you depression, hating your job, being in an unhappy relationship, then you must deal with these things in order to recover. Get into therapy. Get into group. Go to a 12 step meeting if one applies. There are interns and trainees who can see you for little money.  You must prioritize self care if you are to recover from these behaviors. 

Being able to handle having had a bad day and put it in perspective may well be the single most important thing necessary to recovery. I believe that once we have a string of good days, the part of our psyche that has always had the behavior (addiction) to turn to, will panic. And the fear of never being able to do this again causes the addiction in those of us with these disorders to have really overwhelming urges on any one day. And the addiction always wins at that point if we look at our hair and skin and say, Ugh I have ruined it. What's the point?
If however your goal is to get more good days in a shorter period of time, you cannot fail.  See how long it takes to get 30 good days (days that anywhere from a 3 and below to a 7 and a below). Next time around try to do it in a slightly shorter period of time. No matter how much you pull or pick, you cannot "undo" the success of having worked toward 30 good days in, say, 45 (or whatever your goal is). Eventually yes you will have hair and skin you are far happier with. But racking up good days is always your goal. 

So in the case of even if you have to white knuckle it (holding on so tight to something your knuckles turn white) to not get many 8-10s in row, do it JUST for today. Just till midnight or 6am the next morning. Not forever. Tell yourself, I can pull or pick tomorrow if I need to. (And you can.). And that there's a good chance after that day passes the craving will be a little easier the next day.  The reason you can't stop is you tell yourself, I'll never be able to resist this forever so I may as well just pull / pick.  And no you can't resist the urge forever.  And you won't have to. As you pull or pick less and less, IF you are adding in self care to the recovery process, the urges will slowly die. Self care means checking in on your emotional and bodily needs, saying NO & setting boundaries when you are too tired or sad or hungry or in need of down time to say yes. If you "have a hard time saying no," then you will need to get help with that. Because until you can set boundaries, you will not fully recover. 

You'll also need to begin integrating relaxation into your life as you slowly pick or pull less and less. One simple example is the 4-4-4 technique. Close your eyes.  Inhale slowly to the count of four. Hold for a count of four. Exhale slowly to the count of 4.  Do this before you sit down at the computer or to watch TV or before drive or go to bed. You can do it more than once but even once will help. 

I marked days off on a calendar with Xs. At that time I didn't think about the numbers. X was a pretty good day. And I would focus on how I just needed to get through another hour. Or I would shower. Or go to the gym. I figured that if I could string 30 days together that were low pulling if not zero that it would get easier. That's all I thought about. Not my hair. Just trying to get 30 pretty good days. If I had a bad day I would still see my monthly calendar on the wall with lots of Xs. So I just kept going.  

Each day when I wanted to pull badly or in fact had already started to pull, I told myself I just had to do this for the day. NOT forever. The "stopping forever" feeling is sure to cause a strong desire to pull. So I knew it wasn't forever. Just one more day. If possible. I promised myself I could pull if I needed to the next day. And sometimes if I had to be reading or just needed to relax and I could not stop, I would slather my hair with conditioner (which I've told you) because otherwise I couldn't lie there still. For skin pickers, cover your mirror.  Or put a mask on your face at those times.  Or change the energy.  Jump in the shower. Make tea. Sit and know the tea is symbolic of a needed time out and symbolizes starting over. 

It's basically like, Ok This is the path. It is ALWAYS just for today. Just till midnight. You keep going & you get there eventually. And "there" is having 30 pretty good days within a larger period of time as an initial goal. Nothing more.  Ultimately the mind is more in control than the body because the mind can choose to keep trying. The body may force you to give in but the mind will help you to not give up. 

Any one day that isn't good in terms of pulling or picking is a chance to tell yourself, Hey this was going to happen. This is hard! The addiction is what is telling me that this bad day means it's "hopeless.". That you will "never" get better so you "might as well keep pulling or picking.). Because the addictive part of the brain just wants to give you one more reason you won't be able to stop (so you continue doing the behavior the addiction is craving.) One more rationalization. One must say, "ah, there is the addiction talking. Thanks for sharing." to that thought. It is NEVER about the current state of your hair or skin. It is never about perfection or stopping forever. It is always about doing a little bit better just in this moment. 

If you had a bad day, be kind to yourself.  You are already bummed after all. You didn't ask for this disorder and it isn't your fault you have it.  Your addiction wants you to give up and give in because then you will indulge in the behavior you are addicted to. No matter how bummed you are, I PROMISE you this, it is NOT hopeless. I pulled daily constantly for 25 years. Now I don't. And I know so many people who picked or pulled and have gone through this and have stopped you cannot imagine. Recognize that it is the addiction whispering to you to make you feel and think, there is no point, it's hopeless, I'll never get better SO I MIGHT AS WELL PULL OR PICK  Whatever else it does, if you refuse to let the addiction get you to give up, that is the most important thing, and then you are in recovery. And it gets easier. It really does. 

If you continue to blame yourself and attack yourself and feel you are weak or "pathetic" because have this "disorder" (and perhaps you don't even believe it's a "real disorder"), then you will need to work on that attitude first and foremost.  Read "Radical Acceptance: Living Your Life With the Heart of a Buddha" by Tara Brach.  When you are able to integrate those ideas into your relationship with yourself, you will be able to start making progress.  

I wish all of you healing and comfort as you continue on your journey. 

Claudia  

You CAN Recover From. Hair Pulling in 2014: Here is How

There's all this talk about CBT therapy being the "most" effective. I agree more with the "C" (cognitive) part than the "B" part (behavioral). The bottom line is, if you don't change the way you look at hair pulling* (*applies to skin picking throughout) there is no lasting recovery. Just today someone told me, "I was doing better and having lower numbers* for several months. Then I started pulling more and more and felt hopeless, and now I'm back where I was." (*Earlier in this blog I suggest people write down ONE number every day re their pulling or picking. Rate your pulling from 0 to 10, 0 being zero pulling, 10 being your worst day. That will be your "scale." That will be the one and only way you know you are recovering. NOT the hair on your head or lashes or brows. JUST the numbers. And the goal is to move from month to month having overall lower numbers with the understanding that you will have some bad days and that real success is accepting those and moving on.)

The person above who did better for a while and then had some bad days and felt hopeless again and gave up, her story embodies all our stories. Whether the length of time you've done better is a few months, a few weeks, a few days, a few hours or a few minutes, and the return to increased pulling is a moment, a day or a week, that step backwards is everyone's undoing. It was my story when I was pulling. Unless you can live through that moment and know it's part of the process, CBT or meditation or any other method will fail You. Because recovery is, will be, two steps forward, one step back. It will be three steps forward, two steps back. It may be eight steps forward, five steps back. You have not "gone backward," you have not "undone your progress." Because progress won't show on your head or your face (lashes, brows, skin) until later. Until you've done well, had that bad day or two, put it into context (the addiction trying to trick you into hopelessness so you will pull or pick), accepted it, checked not your hair or face right then but rather the general improvement in overall numbers, you CAN NOT RECOVER. Once you can see that those bad days will come and not let them deter you, your recovery is ASSURED.

 Prepare for that. Because as you learn to live without the comfort of pulling to turn to, the part of your psyche where your addiction is lodged, will get scared. For food addicts it is scary not to have comfort food to turn to. And that fear will inevitably cause, urge, cajole and tempt you to binge on something in the midst of changing over to healthy eating and moderation. With pulling that fear will cause you to have a few binge pulling days. And if at that time you say, "Forget it. I can't do this. I messed up. I failed, I'll never lose the weight," YOU WILL GIVE UP. You will say, as we all have, what's the point? It doesn't matter. I've ruined it.

Ah but you have not. Because you won't stop suddenly and completely. You'll stop gradually. And you'll have bad days in there. And if you learn not to judge them or panic or tell yourself, SEE I have failed, THEN you will have succeeded. Eventually you won't have to have those bad days. But the problem isn't those bad days. It's allowing those INEVITABLE bad days to stop you.

Because this will take a year. A year on the path. And then your hair will grow back. Your skin will heal. And if you demand this take three months, well it just won't happen at all. I know a year is a long time. But so is FOREVER. Do you want to pull one more year or forever?

During this year your motivation simply cannot be about how you look or your hair growing in but about feeling good about yourself. About feeling whole. Saying "fuck it I'm ugly" is the addiction talking. Saying "there is no point" is the addiction talking. Saying "I don't care" is the addiction talking.

The only way to avoid that is to understand that at the beginning you must focus on feeling good or at least better about yourself because you are working on the pulling. And writing down a number every day and focusing on improving the numbers and seeing them get lower each month that goes by, will keep you motivated. Knowing that you could feel proud the next day or next week is motivation. Knowing that judging yourself along the way is simply the addiction talking will keep you motivated.

It is NOT YOUR FAULT you have Trich or skin picking disorder. But it is your responsibility to face it. When you say, "I don't care" to give yourself temporary permission to pull you are lying to yourself. Of course you care. That doesn't mean you can always stop in that moment but you care. Pulling for all intents and purposes is an addiction. And you are a slave to it. So care about THAT.
It's NOT, I am bad, what's wrong with me, it's more, This is costing me a lot and is keeping you from living the life you want. That's why I care.

Above all else do not beat yourself up. Do not ask yourself WHY over and over again or What is wrong with me??. (Answer: Because you have trich or CSP. There is no other reason.)  

One cannot recover without shifting the center of motivation from hair to how I feel about myself, how this affects my life. Because the hair takes time to grow. If it's about the hair everyone fails. Because it's too easy to say that, well it looks like shit now so I may as well pull.

That is pretty much why people can't recover: Well my hair or lashes and brows or face looks like shit anyway (thus there will be no immediate payoff) so I might as well pull.

Imagine a person who weighs 350 lbs trying to lose weight. All they have is the scale to help them to see they are losing weight. They can't see it on their body right away. All you'll have for now is those numbers going down. This person who weighs 350 lbs must be proud that they are undertaking the journey. No new clothes shopping now perhaps. Maybe they don't feel pretty. But they are achieving a goal. Of lower numbers on the scale. And they can and must feel good about in order to keep going.

At the end of this thing you will have your hair. But at first make it your business to have lower numbers one month to the next and prepare for those inevitable bad days and they need not take you down.

I KNOW that you can recover from pulling. And believe me, I never thought I could either. But now I know different. The only substitute for pulling is self-acceptance and self-love, self-care and setting boundaries. Read Radical Acceptance. Read Codependent No More. And since it should be said, Take a day or night off just for you.  Exercise. Eat healthy good. Sleep well. Say NO once in a while.  Don't remain friends with people who are takers. Don't wait till you stop pulling to live life and to enjoy life. I'll be happy to answer questions here if you have them.

For Parents of Children With Trichotillomania and Compulsive Skin Picking

Since 1996 I've met hundreds of parents of children and teens with trichotillomania and CSP, both in my practice and at talks and workshops I've given all over the country. I've discovered that even the most well-meaning parents--especially the most well-meaning, perhaps--need guidance as to what their role is in trich recovery and that getting it can make all the difference for their kids.

First of all, as parents you must accept that what your kid has a problem with is not life-threatening, is not evidence of a severe psychological order or that your child was abused.  It is not a deadly disease and it's not the end of the world: It is just HAIR. (Or skin as the case may be.) The more YOU panic, the more your child will. The only way to conquer trich and skin picking is to do so from a calm place, a place of acceptance, a place where one can tolerate the fact that recovery is two steps forward, one step back. And the only way these things can be conquered is when the person who is experiencing them are ready.

Yes I KNOW you are worried about your child at school, your child at prom, your child's self-esteem, your child loving him or herself.  But if your child isn't ready, if the hair pulling is not yet bothering your child at age 8, then dragging him or her to doctor after doctor, and therapist after therapist, and putting them on medication, will only do one thing: Convince your child she is defective. And what you need to do is just the opposite.

I've met MANY 8-year-old hair pullers. When I ask them if they want to stop, at first they say yes. When I ask them if they are bothered by the pulling, they ultimately admit that what they are bothered by is that their mom is so upset. I cannot tell you how many times I've heard this.  If that is where your child is, then sure, they will benefit from knowing about trich, from attending a Trichotillomania Learning Center (TLC) conference with you (trich.org), which is great for the whole family.  I will often meet with a child that age once and explain to them what trich is and that it's a disorder, that other kids have it, and that it's not their fault.  I also tell them that I used to pull my hair out, too, and that if they ever want help with this, to ask their mom and I know she will bring them back. And in many if not all of those cases, the child will ask their parents to bring them back to see me when they turn about 11 or 12.

Then there is the child or teen who is upset about having trich.  Please hear me on this. If you go into panic mode here that is how you are teaching your child to deal with having trich.  And that most assuredly will fail.  What you MUST do is console your child.  Say, I know it is upsetting honey, and it's certainly not fair, but we will get through this together. I will take you to see someone who knows about trich and they will be able to help you. I know you're upset and scared honey, but, you know what? I believe in you and I love you.  I know you are upset about your hair/skin, but I want you to know you are a wonderful, beautiful, lovable person. You don't have to stop pulling for that to be true. Trich is a disorder that they are learning more and more about.  We will find someone who will help. And in the meantime, don't blame yourself or get mad at yourself for having this disorder.  It is not your fault. I want you to know you a extraordinary person and this does not change that fact one bit.

In terms of exactly HOW your child can stop, the answer is, you cannot help them stop. They MUST see a professional. You as a parent, even if you ARE a psychotherapist, cannot help your own child stop pulling, although you can help your child have the best chance of recovering by accepting them just as they are and loving them no matter what. If you do nothing else, please stop telling your child things like, "Stop pulling, honey." "Get your hands out of your hair," or "Stop touching your skin." Do not ask them how the recovery from pulling is going every day. Do not examine their head to see how much they've pulled.  Do not say, you had better stop or you will be bald, if you don't stop you won't have any lashes or brows and those may not grow back. All these messages will create anxiety and fear in your child and make it that much harder to stop. And that anxiety and fear is YOURS, not your child's.

You must be the one who is calm and reassuring. You are the adult.  If you see your child pulling, feel free to say, Honey, could you come here for a moment? Or, Take a look at this! Or say something that allows them to stop without calling attention to it.  If they are sitting somewhere, go over to them and hug them. The thing you need to do is to help your child learn to self-soothe.  If their anxiety is met with your anxiety, they will have no way to deal with things that scare them or upset them or make them feel stressed.  And we all know there are plenty of those.  At present they are using hair pulling to calm themselves down.  So getting upset with them and constantly pointing out what they are doing and making them feel just the opposite of soothed will only cause them to pull more.  Telling them, Sweetie, I know it's upsetting but you will get through this.  This disorder is challenging and I know you feel sad and upset, but we will get help and do everything we can to help.  You are not "ugly" and you are not "weird." You are my beautiful daughter and trich can't change that! A lot of people have this disorder.  I know it still hurts and is upsetting, but I want you to know how much I love you and believe in you. This will be OK. We will find out all we can and we will face this together!

This kind of support, where you reassure your child, you tell your child that it's OK to hurt, but also to know that you will get through this, to reassure your child that he/she is still beautiful and lovable, that he/she is still worthy, that these confusing things happen and that they can get through them, this will help your child learn to self-soothe.  And learning to self soothe is pretty much the only "substitute" for hair pulling.

One other thing about examining their head or eyes, knocking on the bathroom door, telling them to stop touching their hair: It is their body, not yours. They have the disorder, not you, and they have to become ready to deal with it, rather than work on recovery because you want them to.  It's quite important for children with trich to have those boundaries respected, because often they feel so exposed to the world as it is.  Children, all children, need dignity and respect.  But when you have a disorder that is exposed to the world, even more so.  Once you let your child know what trich is, maybe meet with a therapist to have them explain it further and allow your child to ask any questions, then allow your child to decide when she is ready to address the trich. The more you allow your child space to decide and respect their decision, the quicker that time will likely be. And yes I know it's hard to see your child hurting. But pain is a part of life, even for a child.  The more you comfort him, the more you let him know that it's OK to be sad or upset and reassure him that he will get through this, the more equipped to deal with emotional pain he will be.

Most importantly, don't forget all the other things about your child (or your other children).  Don't make trich the sole topic of conversation with your child. Ask about school work, friends, dance, track or whatever else your child is doing. Chances are most 8-yr-olds won't be able to address this themselves at that age. You can consult with a therapist, you can help them understand what is happening to them, you can find a way to cover up their hair or brows in some way.  But you cannot force them to stop or motivate them to stop.  Those of us who have trich do not need additional motivation. We want to stop and you can't make us want it more. Or if we are 8, we may actually not care what we look like that much. So it's really you that is upset, not us.

The reason I say that parents need help too is because most parents are not able to be calm and relaxed and supportive when their child says, I'm so upset about my hair. Or when their younger child has some missing lashes or patches of hair. Of course it's important to seek help, to find a therapist, to become a member of TLC and receive all their information.  But what is also important is that you not panic and that you not hold this as if it's the end of the world.  Your child will learn how to see him or herself from you. The more you panic and the more you behave as if this is a disaster, the more pressured and stressed your child will feel. The main source of stress from most kids I see is their parents' relentless worry about the trich. The child ends up having to calm the parents down and ignore their own feelings.  This is SO common I cannot tell you.  And it becomes a huge block to recovery.

So if you cannot calm down, that's human and understandable.  But seek help rather than sharing your fear with your child via constant advice and questions.  Find a therapist you can vent to, someone who knows not to panic, who can hear your panic and who can help you get through your own fears. If you don't, you will pass your fear on to your child and your child will become the caretaker.  The more you can remain centered, the more you can comfort your child, reassure your child, let your child know that he or she is not defined by trich, that he or she is lovable just as she is right now.

Straight Talk on Trich

I was interviewed last week about Trichotillomania and we covered so much the interview is being run in two parts. Check out Part I on the link below:

http://bingebehavior.com/qampa/claudia-miles-3lmft-compulsive-hair-pulling-trichotillomania-straight-talk

Straight Talk About Trich: An Interview

I just did an interview about Trich and answered many common questions about the disorder. Here's a   link to Part I.

http://bingebehavior.com/qampa/claudia-miles-lmft-compulsive-hair-pulling-trichotillomania-straight-talk

Does Pulling Split Ends Count? )

Q. Does pulling split ends count as pulling? I'm not pulling the root out... Or is that like an alcoholic licking an empty but frothy beer glass... ?

A. In a sense, yes, since it will likely trigger you to pull other hairs out.  Also, many people who pull do not pull hair out by the root. Many others do. This does not define whether you have trich or not. But it all comes down to what you can live with. I've had clients who find playing with or smoothing their hair with their hands to be a trigger, and others who do not. For a few, being able to smooth their hair down actually makes it easier for them not to pull.  For almost everyone else, that's not the case. If pulling split ends somehow did not lead to you doing more, and you could live with the result of just doing that, that's perfectly fine.  However in 98% of cases, it's going to be a trigger to continue to pull. If split ends both you, I suggest getting your ends trimmed regularly.  

The key is to stop pretending there is certain kinds of pulling that "doesn't count." If you pull out gray or coarse hairs, that is compulsive hair pulling, and that's how we give ourselves permission to start picking or pulling. (I'll just pull this coarse one.) After we pull that one hair of course we disappear into trance and it's 30 minutes to two hours later till we "wake up" filled with shame or disgust and wonder, how did this happen? It's not unlike the alcoholic who tells himself, I'm not drinking to get drunk, I'm just having one glass of wine at dinner. Yet for this guy, every time he has one glass of wine at dinner, he is compelled to have 10 shots of tequila later on in the evening. This guy has to acknowledge that the glass of wine at dinner, for him, is part of the addiction. Next time he needs to be honest with himself: I know I'd love to be able to have a glass of wine with dinner, but the reality is it will lead to drinking alcoholically and I'm not going to pretend if isn't.  

In order to recover from compulsive hair pulling, we have to get out of denial. Even if one is not ready or able to consider pulling any less, all you need to do is simply acknowledge that the coarse hair you are pulling is in fact a response to the craving to pull. And to tell yourself--with kindness and compassion--I know I really want to make it OK to pull this ONE coarse hair and pretend this isn't the trich, but I'm not going to do that right now. I'm at least going to admit to myself that the desire to pull that hair is the same craving that causes me to keep pulling my hair out. I may not feel able to resist that urge right now, but I'm not going to pretend that it won't lead to more pulling. What I will do is acknowledge that even though it will cause me emotional pain, I feel unable to resist this urge to pull. Which just shows how very powerful this addiction is. 

If you are just beginning recovery, or if you haven't done this yet, the important thing is that you acknowledge what's happening. If you start to tell yourself, I'm just going to pull a gray or coarse hair or pick at my split ends, bring mindfulness to the situation. And acknowledge that chances are, you will keep pulling once you start, if you start.  You might say, ah, there's the trich wanting to convince me to start. OK I see. That's how it works... Just observe it, without judgement.  Trich is a disorder, and it causes people to crave this experience of pulling out our hair.  It actually feels good and soothing and that's why we keep doing it. Trich is NOT you WANTING to deface yourself or sabotage yourself or anything of the kind.  It's a pleasurable sensation that frustratingly causes hair loss. 

It's better to choose to pull knowingly than to feel or believe "it just happened." Better to choose to pull the gray hair knowing where it will lead (and being compassionate about how hard it is to resist this urge) than to keep saying, I don't know how this happened.  If you can CHOOSE to pull, ONE DAY you will be able to CHOOSE NOT TO. You WILL be successful. Just don't give up.  



Please send me any questions you have about recovery: claudiamilesmft@gmail.com  

Tune in to Your Own Needs and Feelings

One central issue hair pullers and skin pickers often possess is they aren't really sure how they feel at any given moment.  What they do know is how others feel.  You may be sitting in a room with a few people and be thinking: Jeannette seems mad (is she mad at me?); Bob seems bored, I wonder how I can get him more interested in the topic; Joan seems tired, she should probably sit down instead of helping in the kitchen; everyone must be hungry, I'll make a deli run.  You don't notice it, but you aren't aware whether you are mad or bored or tired or hungry, but rather, focused on taking care of others' needs.

The problem with this is, if you don't know how you feel, you are likely projecting your feelings onto others and taking care of the needs you believe they have, rather than your own. That's probably because fear caring for yourself means you are SELFISH or LAZY.  It's selfish to think of yourself; it's lazy to rest because you are tired. You might be surprised how many people with TTM and CSP believe these things.  That's because most of us with these disorders grew up in a home where for a variety of reasons they felt their survival depended upon taking care of others' needs.

Some examples of this include:

A client whose father was prone to rages and whose entire family was focused on not making him angry which was very hard to predict
A client who, at age 10, found out her mom was having an affair and who told her dad. The two never discussed it with her (or seemingly each other) and it was deadly quiet in the home. This woman planned things like Valentine's Day dinners for her parents, because she feared they would break-up. She was very attuned to what they were feeling, but since everyone was busy ignoring the elephant in the room, no one even asked her how she felt
A client who found out her mom had breast cancer when she was four. She learned to ignore her feelings because she did not want to share them with her mom and add to mom's burden.  Besides, anything she felt couldn't be that "big a deal" compared to what her mom was going through. This wasn't what her mom wanted, but nonetheless it happened.

If you don't tend to know how you feel or what's right for you, if you tend  to agonize over the "right" decision, no matter how big or how small, if you aren't aware of what's right for you, and instead focus on what you "should" do, if you wait to go to the bathroom till the last possible minute, if you try to make sure everyone around you is happy or at least not mad or disappointed and are aware of how most others around you feel, yet you don't know what you feel or whether you are OK, if you do know how you feel but think it would be selfish or lazy to fulfill those needs, then an important part of recovery is learning to tune in to your own needs and feelings. How many times have you had an important decision to make about your life like whether to get a divorce, whether to take or leave a job, whether to move, and you've asked every single person you know what they think you should do? Doesn't it make sense to get advice you ask? Not really. Not about something that will affect primarily you and that only you can know the answer to. Do you want to live the life the person whose advice you are asking would lead, or do you want to live your life? At the very least, you have to know what you really want. The question is not, What if you make a mistake, because you will.  It's more like, how can you start to accept that you will make mistakes and that that does not make you less worthy?

Pulling and picking behaviors may not be caused solely by not knowing yourself, but the behaviors definitely play a part in helping you numb the pain of ignoring your needs and feelings.  The more you learn to tune in to what you feel, what your opinion is, what you need, the less you need pulling or picking to numb these things.  In other words, knowing what you're feeling will help you stop pulling and picking. It isn't that you'll be able to meet every need, address every feeling of course, but that the vulnerable part of yourself, the part that does the pulling, will start of be able to relax and know that IT will be heard. It will no longer be ignored.  Those fears, that pain, can cause urges to pick and to pull to be more frequent and stronger.  The more you learn about what you feel, what you need, what you believe, the more you pay attention to what was likely ignored for a long time, the less anxiety you will have.  Chances are that in meeting others' needs you have some vague hope that they will meet your needs in return.  That rarely happens, though.  One reason is that those who would take take take from you, are takers, not givers!  And those are the folks you are probably giving to.  Another reason is that your partner, spouse, best friend, lover may not realize what you are doing.  I know you think it's obvious but it's not.

Another reason it may be scary to know how you feel is that then you will actually have to feel it. You may be afraid those feelings will last forever or that it's self-indulgent to feel them.  I've heard many people say things like, "If I allow myself to be sad, I'm afraid I'll never stop crying," or "What do you mean allow myself to grieve? That's all I've been doing for 10 years." Sometimes people believe that allowing themselves to feel grief, sadness or anger is self-indulgent or weak or unfair. They will say, "I shouldn't be sad after all this time," "How can I really be angry at my mother when she did the best she could," or "At this point I think my grief is just me being a baby."

The truth is, when it comes to feelings, whatever you resist, persists.  If you refuse to allow yourself to grief or be sad, it will be there all the time, just beneath the surface.  That's why you may cry at movies or Hallmark commercials at the drop of a hat.  In terms of whether you "should" feel how you feel, it's simply not a matter of should.  Feelings just ARE.  They exist.  If we spent 1/4 the energy allowing ourselves to feel them as we do pushing them down, they would be long gone.  And what about being angry? Anger is a feeling, not a betrayal.  And everyone has reason to feel anger at their parents.  It certainly doesn't mean you don't love them.  Even if your parents did do the best they could, it doesn't change the fact that you're affected by them, just as they were affected by their parents. Being angry at someone is different than blaming them or cutting them off.  Underneath the anger you are probably hurt.

1) Practice tuning in to what you feel and what your wants and needs are even if you don't change what you do.  Ask yourself, do I really want to go that event? Do I want to help so and so with her move? If you start to think, I should go, I should help, then you will know you aren't tuned in to what you feel.  It's OK if you go, but ask yourself what you really feel.  Find out if you are resentful.  One person might tell me, "My mom calls three times a week, and I have to talk to her because if I don't she gets really hurt." Well it seems your MOM knows how she feels!  But why does her need to talk to you or her "hurt" supersede your need to have time to yourself, to NOT talk, to rest?

2) Allow yourself to have your feelings (say, OK I'm sad right now, instead of, how can I stop being sad) and understand that you can't know how long a feeling is supposed to take.  That doesn't mean neglect your job, your kids, your partner, your friends, but it does mean that you stop saying to yourself that you "shouldn't" feel sad about X for so long or that you can't be angry at someone in your life because they did the best they could.  All that angry that you believe you aren't allowed to feel you actually are feeling, but only at yourself.  You are judging yourself, criticizing yourself, telling yourself you'r'e a failure or that you are stupid or selfish or pathetic or lazy or weak.  If you aren't allowed to feel your anger it becomes a toxic soup inside you.  You don't need to be violent, you don't need to yell, you don't need to necessarily tell others that you're angry, but you need to allow yourself to acknowledge and know it is OK to feel it.

3) Notice your judgements about all these things. Do you fear you are selfish or lazy? Do you think it's not OK to be angry? Are you unable to separate what you really want with what you think you should do?  Notice your fears of making a decision based on what you believe is right for you.  You don't have to get rid of these judgements, just be mindful of them.

Simply knowing the difference between what you really want and what you think you should do, and what you really feel and what you really should feel, will allow the part of you that has felt neglected or unloved or vulnerable to start feeling seen.  Just the very fact that you know and pay attention to that voice inside will calm the voice down. Someone is paying attention.  You.  It's the beginning of reparenting yourself and it's an important step in trich and skin picking recovery. This is something you can address no matter where you are in your recovery.  I hope you will start to investigate!

The Path to Recovery: An Overview and Reminder

I believe the path to hair pulling and skin picking recovery includes the following steps:

1) Learn to accept & love yourself whether you're pulling or not If you withhold self-acceptance until you have complete recovery you create a battle ground within yourself. (Read Radical Acceptance by Tara Brach.) This is NOT the same as giving up, or accepting the pulling will never change. This is accepting yourself, regardless of whether you are still pulling or picking; not making your self love conditional.

2) Keep a calendar and rate each day from 0 to 10, 0 being 0 pulling or picking, 10 being your worst day. This will be your "scale" so that you can see improvement, even if you can't see it on your head, face or body. If one month has 9s, 8s and 7s, and the next has 8s, 6s and 4s, you may not see a physical change yet, but you are on your way. This helps when you have a bad day. My blog at HelpForHairPullers.blogspot.com will expand on this.

3) People always ask, Is there a substitute for pulling or picking? Something I can do with my hands? I say, the real substitute is something you do with your MIND. If you usually go go go all day, and then suddenly sit down to watch a movie, get on the computer, read, and find yourself pulling or picking, then pulling is aiding you in the transition from doing to not-doing. Instead of trying to fight the pulling, you want to adopt a nightly ritual that will help the body release stress Before you sit down to read, watch TV, et al. I suggest before you sit down with a book or TV, SIT for FIVE minutes and either do a relaxation exercise (inhale relaxation, exhale stress, tension & tightness) or do a mindfulness meditation for five minutes. Your mind & body then get a chance to make the transition into a state of relaxation. Your urges will begin to lessen as you do this since you've already addressed one of the reasons you have urges.

4) Bring awareness to your conscious mind: I once worked with a 60-ish woman who had a severe cuticle picking problem. It was so bad her hands were bloody and nicked, and she was deeply ashamed. I asked her if she did this all day or at specific times. Oh it's always the same, she said. I sit down at 5pm for an hour before my husband comes home and read the paper and have a glass of wine. That's when I pull. So I asked her, Do you think about it before you sit down? Do you bring to mind the fact that this a dangerous time for you? She said she did not. "I guess I don't want to think about it because I'm always hoping that I won't do it." When I asked her if there was ever a time in the past 35 years that she didn't pick, she said no. I explained that what she called "hope," I called denial. I urged her to simply acknowledge to herself before she sat down that this was a danger time for her, and it was important to be aware. This often is not always enough to make a change, but for this woman, acknowledging to herself before hand that this was a dangerous time for her allowed her to stop picking entirely.   For other people it is one small piece in the bigger puzzle of trich and CSP recovery.

5) Until you understand & accept that recovery is a gradual process, you are unlikely to be able to recover long term. Pullers and pickers often proudly tell me they are perfectionists. Here's the problem. If you are perfectionist, you are, by definition, a failure. Humans are not perfect, cannot be. So if you set a standard for yourself that is unattainable, you will always feel bad about yourself. The reason I suggest using a daily number (#2 above) is because recovery is generally a two steps forward, one step back kind of thing. The reason it's so tough to recover from these disorders is that it's quite common to have a "bad day" after having several good ones. And it's just as common to think to yourself, "Oh boy, I ruined everything. Here I was doing well, and now I've messed it up. I guess I'll NEVER recover, so I MIGHT AS WELL JUST PULL (or pick). That voice--the one that tells you that you'll "never" recover? That's the trich or CSP addiction talking. Think about it. If you tell yourself that you'll "never recover," you're free to pull or pick! If you are a perfectionist about this, you are saying that either you suddenly stop and stay stopped 100% or you are a failure. Since that's unlikely to happen, you in fact have now made it impossible to recover. What if, in order to get to zero, you have to achieve less and less pulling first? You might say, I did so well for three weeks, and I "ruined" everything all in one day. NOPE, not true, that's impossible in fact. If you pulled very little or none for three weeks, and had one bad day, that means 21 of 22 days were good or even great. This is a huge improvement. And yes, I understand that you pulled out a bunch of hair and picked a bunch of skin. However, you didn't "ruin" your progress. The more days you have where you pull less, the faster overall you'll grow back your hair or heal up your skin.

6) Change your short-term goal. If your goal is to have your hair back or to have your skin clear, that's always six months in the future. Your short term goal must be to feel good about yourself for improving and to validate yourself for any gains made, including gains made in awareness and self-talk, as opposed to lessening of the behavior. If you often say, I was so "good" for a while; now I've "messed" things up again. I have so little hair, or my skin is so messed up, "what's the point" in trying to stop now. I look terrible anyway (and I'll probably just pull or pick tomorrow). Here's the POINT: You will feel better about yourself later if you pull even a little bit less right now. And if you don't, you can learn to celebrate small victories.  You have to admit you will probably feel bad if you continue to pick or to pull. So at the very least you are avoiding that. The POINT is, recovery is gradual. The hair and the clear skin come later: the small steps happen now. The POINT is, taking any step, however small, is a step toward recovery.  This is a great point! The POINT is, Hey, even though I tried to tell myself that my hair is so messed up I might as well pull, I did NOT pull. Each day that goes on, and that you pull a little less, is another day that you can remind yourself, hey, I'm doing this. I'm making small steps these will add up. Good for ME! And every day you are able to pull or pick the smallest bit less, you are closer to the long term goals around hair or skin.

Changing the way you look at this so you understand it is not your fault that you have trich (but like any other disorder you could have, it's your responsibility to yourself to address it), encouraging and supporting yourself as you recover, becoming more mindful, taking five minutes before those transition times to relax your body and mind, keeping track of the days with a single number (so you can look back and see that, hey, overall the numbers are getting lower), and accepting yourself no matter what, these are all important pieces on the path to recovery. Everyone can get there. Congratulations. You are on the path.

You Cannot Stop Pulling Until You Accept That You Cannot Stop Pulling

There is one central and seemingly paradoxical truth when it comes to recovery from trichtotillomania and until you address it you will be stymied in your efforts to recover:

YOU CANNOT STOP PULLING UNTIL YOU ACCEPT THAT 

YOU CANNOT STOP PULLING

Confusing? If you can't stop pulling then how can you, in fact, stop pulling? Or perhaps you are thinking, well of course I know I can't stop pulling or I wouldn't be googling hair pulling and I wouldn't be reading this blog. What I mean by the above statement is this.  People with trichotillomania (TTM) and CSP refuse to accept and to believe that the TTM and CSP are real disorders. Pullers continue to tell themselves that they "should" be able to just stop pulling and continue to attack themselves because they cannot stop pulling. We believe pulling and picking are the result of a some kind of psychological weakness and the reason we can't stop lies in our character.  This is entirely untrue. We can't stop puling and picking because our bodies and minds continue to produce intense urges and cravings to pull, many of which catch us off-guard, and in order to stop we have to face what is actually happening and respond to it.

The current Diagnostic and Statistical Manual of Psychiatric Disorders (DSM IV)  definition of TTM (and thus, CSP) aids in this self-deception. The description reads: The inability to resist the urge to pull out one's own hair.  (By extension, the definition of CSP would be the inability to resist the urge to pick at one's skin).  I would beg to differ here (and when the DSM V comes out, there will be changes made to the current description). I believe the definition should be:

Trichtotillomania/CSP: HAVING the urge to pull out one's own hair (or pick at one's own skin) to such an extent that despite multiple efforts to stop doing so, the constant presence of the urge and the constant urging by the body and mind to respond to the urge, makes it overwhelmingly difficult to stop doing so to such an extent, these conditions are disorders. 

If you believe you SHOULD be able to stop pulling you are denying the fact that this is a real disorder and you carry a great deal of shame, blame and even self-hatred. Continuing to tell yourself that "this is ridiculous" and that you  "should be able to stop" is the single biggest issue preventing you from doing so because it keeps you in denial. Until you get out of denial and accept that the disorder is real and NOT YOUR FAULT you simply cannot progress.

WHAT DENIAL DOES TO IMPEDE RECOVERY

If you do not accept that TTM & CSP are "real" disorders but rather believe you "should" be able to "just stop" the following occurs:

A) Because you don't believe TTM is a real disorder but is something to be ashamed of, you spend more time hiding the symptoms of the disorder and finding ways to prevent people from finding out than you do dealing with the disorder.**
B) You blame, judge, chide and attack yourself for having the disorder daily which increases the desire to pull or pick.
C) You are filled with shame and believe that having this disorder makes you an inferior person
D) You don't get professional help because you're ashamed
E) You don't get support from friends or your partner (even if that means educating them about it) because you expect that they will have the same judgmental, finger-wagging, sense of disgust about it that you do***.
F) You minimize a problem that is large making it impossible for you to do what is needed to face this.
G) You are unable to slowly reduce your pulling & picking, the most effective and long-lasting way of stopping, because you decide any amount of pulling or picking is "wrong." With any other "real" disorder it would be obvious gradual improvement is exactly how to recover.  If you are depressed, you don't expect to go from feeling depressed to feeling great in one day.  You understand that you will do a little better each day, and eventually you will feel better. With pulling and picking, as you learn to work with your body (not against it) and gradually reduce your pulling and picking (allowing your body and mind to adapt) while at the same time learning to support, encourage, guide and soothe yourself as you go (because you are recovering from a real disorder not a moral failure).

REAL DISORDERS REQUIRE REAL HELP

That's the difference between trichotillomania (TTM) and CSP and any other illness or disorder.  People with other disorders do not have delusional beliefs that they should be able to cure their disorder without help. No one for example believes they should be able to manage diabetes or cancer by sheer power of will.  If they did, they'd have many angst-ridden years in which they attempted to use will power to effect an illness that won't respond to will power (but will, unfortunately, respond negatively to stress). It would become much harder to manage diabetes and reduce or eliminate the symptoms as long as one is saying to one's self, "I shouldn't need to inject myself with insulin, this is ridiculous," or "Diabetes isn't a real disease, I am sure I can just control it if I put my mind to it" or worse, "Stop being so weak and pathetic. Get your blood sugar down just like everybody else. Take control of things! Come on."

Telling yourself on a regular basis that you shouldn't need help and that you should be able to stop
makes as much sense as diabetics telling themselves they should be able to "just lower their blood sugar" without help or that people with OCD should "be able to just chill out and get over their germ phobia" or that people with Tourette's Syndrome should "just be able to 'shut up' instead of giving in to the verbal tics that cause some with Tourette's to say or shout things they don't want to say in public settings.

There are many things one can do to be healthy if one is born with Type 1 Diabetes but until you accept you have Diabetes, that you aren't weak-willed for having diabetes, you really can't do any of that stuff.  You would resist looking at dietary plans, avoid taking classes on diabetes and you sure wouldn't want anyone to know you have diabetes causing you a high level of stress in many situations.  If diabetes was like trich, you'd agonize over going on a camping trip lest someone find out. You'd buy a secret stash of diabetic food and take it in a secret compartment of your backpack so nobody would know. You spend the entire camping trip worrying about how to give yourself injections in private, how to swap your sugar-free diabetic snacks for the shared group snacks and doing everything in your power to stop others from finding out. Can you imagine how this would affect staying healthy and not allowing diabetes to overtake you?

My earlier posts discuss some of the things you will start to do to begin your recovery. Keeping track of  your pulling each day by scoring the overall pulling from zero to 10, zero being zero pulling, 10 being YOUR worst day. Changing your thinking (an ongoing process) described in the 2011 posts. Practicing internal self-soothing (self talk) wherein you learn to support yourself when you are sad, angry, or upset and rather than resist or deny these feelings, accept them, allow them, and tell yourself you will get through them (you will). Learning to transition from one task to another, learning to wind down and not just suddenly stopping after a busy day and expect your body to instantly relax. Pulling and picking may currently be your "transitional" behaviors. These can be replaced with very brief mental and physical relaxation exercises. Finally, mindfulness is important. Reminding yourself, Hey, this is a time I might pull, I just want to bring it to mind and see if I can be more aware rather than pretending each time you sit at the computer (or walk into the bathroom) that "nothing will happen" by not acknowledging the possibility.

However the number one most important step to your recovery is getting out of denial and accepting you have a disorder. It is not your fault you have a disorder but it is your responsibility (to yourself) to address the disorder and to do so with compassion and commitment, not judgment and blame. I have seen many MANY people recover and stop pulling and picking either completely or nearly completely, to the point it doesn't bother them. Every one has stopped the blame game and changed the self-talk and learned to support themselves through recovery. I did. And you can too.

*Pulling and picking can be thought of interchangeably in this post.  Skin picking is a body-focused repetitive disorder just like hair pulling and all the things I discuss here are as relevant to skin pickers as they are to hair pullers.  Skin picking (CSP) is a disorder just as hair pulling (Trichotillomania) is and it is equally true that you cannot stop picking until you accept that this is true. 

**I support you completely in doing whatever makes you most comfortable in covering hair loss or any skin problems you have. My next post will be on Hair Replacement & Scar Reduction/Elimination and will be up in the next week. 

***If your parents have that kind of response it's because they look at you as a reflection of themselves & they feel guilty and responsible for the problem, they want you to stop so they can feel better about themselves. Your friends and partner won't react that way. In 16 years  of working with TTM & CSP clients I would say that 98% of all friends and partners of people with trich and skin picking have responding positively and supportively to the problem.

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. 

HABIT REVERSAL TRAINING

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. 

JOURNALING

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.  

BEHAVIORAL METHODS SUGGEST THE BEHAVIOR IS VOLUNTARY

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. 

WHY NOT TRY ANYWAY?

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.  

THEN WHAT?

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.