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.  

The What: What Do I Do?

Let's say you decide that you want to recover from trich. If so, start right now.  Not tomorrow morning. Not at the beginning of the week. Not at the beginning of the month. NOW. But now doesn't mean force yourself to stop pulling. If you could, you'd already have done so.  

Step One: CHANGE YOUR THINKING  Stop blaming yourself for a condition you can't help having, stop calling yourself gross and disgusting, stop thinking of yourself of less than worthy because of the amount of hair you currently have.  What if you had a best friend with trich? A daughter with trich? Would you call her disgusting? Would you constantly shame her? Doubtful. You'd probably say, Honey, I know this is a really tough battle, and it's painful to deal with, but you will get through it and I WILL BE HERE FOR YOU.  Say to yourself, hey I realize I just pulled for probably an hour.  I'm wanting to tell myself how disgusted I am with myself, but I'm starting to see that there is something beyond my control going on here and I think I'm ready to stop blaming myself.  I am going to find a way to support myself emotionally.  If I hear myself think, "What is wrong with you," I'm simply going to acknowledge the thought by labeling it, "Ah, inner critic." I'll say, "Thank you for sharing." And I'll bring my breath and my body back to the present moment. Thought comes in: Oh my god, what's wrong with you? Awareness of thought. "Ah, inner critic. OK. Alright. Thanks for sharing. Back to the present I'm sitting here. I'm breathing, I'm still..  OK." And this may happen again and again.  And again and again say, OK, hi inner critic, thanks for sharing. I'm going back to the present. I like to think of the inner critic as having the emotional maturity of a three-year-old.  If a three-year-old said to you, You're STUPID, would you fear that, oh my, you really are stupid? It might be annoying, but you'd let it go. Think of the inner critic as a primitive voice or thought that is actually trying to help you (with negative reinforcement), but in a very noneffective way.  The more you can acknowledge, label, move back to the present, the better. In the present you can say, I'm feeling sad or bummed out that the pulling happened. It's hard to experience this. But I won't add insult to injury by blaming myself.

Step Two: NEVER START OVER  It's all part of recovery.  Recovery is the proverbial two steps forward, one step back.  Unless you accept this, unless you stop seeing the "one step back" as failure but rather as a part of recovery as a whole, you cannot recover.  Even though there are cases where people have remissions, and stop pulling completely, it often eventually returns.  And those people don't have the inner strength to continue to stay on the path. If you have by some miracle, or by work or by doing the best you can, a week without pulling, don't be surprised if it's followed by a day of pulling.  Or maybe it will be two days of not pulling and one day of pulling. But I will tell you this: When you can have a few days that you do well, and then have a bad day, and say to yourself, I'm sad, this is hard, BUT THREE out of FOUR days I did really well, THAT IS RECOVERY.

Step Three: KEEP A RECORD In order to know you did well, and how you're doing overall, you must create a little calendar just for this purpose. Make it and print it out.  Just the classic month view calendar with a square for each day of the month.  And each day at the end of the day, rate the day from zero to 10.  Ten is YOUR worst day, zero is, of course, zero.  Each day has a number.  It's one number, once a day. Simply by doing this, you are in recovery. If you forget that night, do it the next morning. But this is doable, and necessary. You won't see progress on your head for quite some time, but it is enormously helpful to know you are making it. And nearly impossible to encourage yourself during a rough time if you don't

If you can do these things, you are in recovery.  Also refer back to Oct. 2011 post and the one after that which focuses in detail about how to change your thinking. If you have questions as you are doing this, please post them or send them.  If I can I will answer them.

Two to four people out of every hundred have trich. You really are not alone.  And you really can eventually stop pulling. But understand it is a gradual process and don't beat yourself up for not being "better," support yourself instead for trying.  I've met so many people with trich and it always amazes me how much stronger they are than they think are. Please be kind to yourself. It does make all the difference.

Why Do I Pull? (Because You Have Trich)

Why do I pull? Why can't I stop?  Would you ask yourself this over and over if you had type 1 diabetes? No you would not.  You pull because you have trich and if you have trich, you have urges and you can't stop because you haven't accepted that you have trich and continue to cling to the idea that you "should" be able to stop.

As long as you blame yourself for having trich, you'll have an impossible roadblock in your recovery. It is not anyone's fault that they have trichotillomania or dermatillomania, no matter what well-meaning friends, boyfriends and girlfriends, spouses, parents or anyone else tells you. Even if your pulling is so unconscious that you aren't actually aware of what the urge feels like (when it's not being satisfied), the urges are there.  As long as you tell yourself over and over how sick, gross, horrid and disgusting pulling or picking is, you are making it harder and harder to get better.

Yes, I know you want your hair back, or your skin clear. Of course you do. And I know you're frustrated with the situation. But that's not the same as constantly beating yourself up about it. The opposite of that, feeling like a victim, is just the other side of the same useless coin. Poor me, I have trich, that means I'm ugly and awful and no one will love me.

Well that's just not TRUE. There are millions of people with trich and millions of people with trich who have people who love them. What's more true is you devalue yourself because you have trich and push people who maybe could love you because you don't want to tell them your horrible secret. I can tell you right now that I've been party to hundreds of people's stories about telling a partner or a friend the truth about their trich or derm. In 99% of the cases, partners (mostly men) have said things like, I love you, not your hair; and I support you in recovery because it bothers you so much, but it makes no difference in how much I love you or how beautiful I think you are.

One woman said that telling men she dated about trich before she slept with them was her jerk-detector. Any guy who had a negative reaction to her having trich, she broke it off with them before it went any further.

So WHY you pull is simple. You have trich. It has a genetic basis and produces urges like itches that the body responds to. (In the case of picking there is a similar mechanism at work, but there is usually an additional issue of wanting one's skin to be perfect.)

In the same way you would scratch if you had an itch, no matter how determined you are not to, if you have urges to pull, your body will unconsciously react while you're distracted. Nearly all pullers pull their hair out when they are reading, studying, watching TV, on the phone, driving, at the computer and perhaps in the bathroom. Often there isn't anything wrong at these times, it's simply that your guard is down and the urge has the chance to be satisfied.

The reason I'm going on about this is so you won't. One of the steps to recovery is to STOP asking yourself WHY you pull.  If you did have Type I diabetes, it wouldn't be a matter of why but a matter of what. What do I do so I can be healthy? Not, I SHOULD be able to reverse the condition and NOT have it. I shouldn't have diabetes. That won't help you at all. The condition of having trich is a compulsive desire to pull out hair and the inability to stop. Quit asking WHY you have trich and stop telling yourself you SHOULD be able to stop, and start asking What do I do since I have trich and it's causing me pain? Getting away from the why to the what is progress.

Let 2012 Be the Year You Commit to Recovery

Happy New Year, All! A new year can inspire many a puller* (*puller or picker) to resolve that "This year I will stop pulling." This can be a set-up for failure however because recovery from Trich & CSP is gradual. It is common for behavioral progress to be characterized by taking three steps forward and two steps back. Also, it's very challenging to commit NOT to do something, especially something that is actually a response to an urge and often happens unconsciously. A better resolution to make is this: This year I commit to being on the path of recovery from Trichotillomania or Compulsive Skin Picking (CSP). Here is a list of things that can lay the groundwork for lifelong recovery. Committing to do any of these things means committing to recovery.

1) Learn about mindfulness meditation. Even if you never have a serious meditation practice, the concepts of mindfulness will allow you to shift your thinking about pulling. I recommend Miracle of Mindfulness by Thich Nhat Hanh. Or if you live somewhere that has a Zen Center (many cities do) most offer weekly talks on mindfulness throughout the week. Try Googling your city and the words mindfulness meditation classes or talks. You can also download some free talks or instruction. Here is one link from UCLA. http://marc.ucla.edu/body.cfm?id=22

2) Practice Self Acceptance. The best book I've ever found on the topic is Radical Acceptance by Tara Brach, Ph.D. You can get the audio version. She has recorded additional audio versions to complement the book. Most folks with Trich & CSP practice "conditional" self-acceptance (or self love). They attack themselves for having a condition over which they presently have no control. They blame themselves for pulling & picking even though these things are done in response to a physiological urge. So long as your self-acceptance is conditional, you are in a Catch-22 situation. If you pull, you hate yourself. If you hate yourself you pull. And since you will pull or pick even as you are recovering, you must learn to love and accept yourself during the process. Tara Brach's book explains exactly how to do this, so I highly recommend it.

3) Change Self-Talk Related to Pulling or Picking. In the post just before this one I outline specifically how to do this. This must be done before one makes progress with behavior reduction or cessation. There are many ways we give ourselves permission to pull, mostly by lying to ourselves. If you change the self talk without worrying about changing the behavior, the behavior will actually change.

4) Don't Fight the Urge, Use Visualization and Breathing to Reduce the Urge. Trying to fight a very strong urge is extremely difficult. If you are pulling and you have a strong urge, rate that urge from 0 to 10. 0 is no urge, 10 is your strongest urge. Maybe a 3 or 4 is an urge you could resist while an 8, 9 or 10 is impossible. Take a few minutes and focus on inhaling and exhaling but say to yourself, With each inhalation I am taking in warmth, calm, soothing energy. With each exhalation I feel my urge lessening. Imagine as you do this the urge is lessening. Say to yourself, With each inhalation I am becoming more relaxed, with each exhalation I feel my urges lessening, just a tiny bit each time. If your urge is a nine, imagine it becoming an 8.5. Then imagine it going down to an 8. Continue on this way until you get the urge down at least a few points lower. Don't try to force yourself not to pull. Just visualize lessening the urge. Maybe you'll do this exercise before you sit down at the computer or before you start reading or studying. Maybe you'll do it in the middle of a pulling session. Even if you continue pulling after you do the exercise, you will almost certainly pull less than if you had not done it.

5) Practice Saying No. Most hair pullers & skin pickers overcommit because they mistakenly think that saying No is selfish or being a good parent or spouse means always saying yes. The pulling or picking is a way of numbing out the resentment that comes from being a caretaker. Sometimes it requires going to therapy to address this issue. However one thing I always recommend for people who overcommit is to practice saying, "Maybe. I need to check my calendar and I'll get back to you in an hour (or tomorrow morning). That way you can spend some time thinking about whether you really DO have time to take on the commitment & whether you will feel resentful if you say yes. If you will feel resentful chances are your pulling will increase. Much pulling and picking is related to this kind of resentment.

6) Start taking N-Acetyl Cysteine if you aren't already taking it. NAC is an amino acid available without a prescription & is the only thing ever proven in a scientific double blind research study to have a measurable impact in reducing pulling. The studies have only been completed in regard to hair pulling, although there is anecdotal evidence it can help skin pickers. You can read my 2011 post on NAC which has a link to the actual study and discusses the dose to take or go to the TLC website at
www.Trich.org and read about it there.

These are just a few steps you can take to begin the journey of Trich and CSP recovery. I will add more things to the list during the next post. If you have any questions for me about recovery, please email me at claudiamilesmft@gmail.com. I will answer questions on the blog anonymously. No one's name or initials will be used.

Let 2012 be the year you commit to recovery.