Whether one is just starting treatment for Trichotillomania or years into recovery, obstacles often appear, causing an apparent impasse. Sometimes it is clear what the barrier to progress is – but sometimes it is subtle and obscure. In this article I will discuss some of the barriers my patients have had to overcome in order to end their hair pulling and start healing from the more internal pain caused by Trichotillomania.
Many of you have contemplated or embarked on a program of treatment and recovery, only to find yourself too immobilized to start, or blocked at a point of partial success, or seeming to slide back down to the bottom of the mountain. There are innumerable reasons why this may be the case. This article will discuss some of those reasons, and what might be done to break through “the brick wall” that stops change and recovery.
Denial of the impact of Trichotillomania in one’s life:
Many people who pull their hair to the point of creating bare eyelids, brows or scalp have never actually seen it as a problem. For those who, for whatever reason, don’t become self-conscious or ashamed by their hair pulling, it is simply not a “disorder”, and they have no strong desire to stop pulling. This attitude should be respected, of course, and there is no need for such individuals to seek treatment. On the other hand, there are some for whom the apparent lack of motivation to change is a mask for a complex set of feelings.
Often the seeming acceptance of their condition is the adaptation they have developed to cope with having hair loss, or to their hopelessness of ever being able to change.
Where there is denial of the emotional pain caused to one’s self through a behavior, one method of producing change is to challenge or “confront” a person with the reality of the problems caused by pulling hair. A skilled therapist can do this gently for a person who is ready to start letting go of their denial. One may do this on their own, too, if there is partial insight into their tendency to minimize the impact of Trichotillomania in his or her life. One technique is to list all the reasons why hair pulling is a problem in one’s life.
Lack of faith in one’s ability to heal: If one cannot believe he or she can stop pulling their hair, recovery will not start. Hopes dashed over and over through disastrous or disappointing encounters with the “helping professions” are one cause for this loss of faith. In the most unfortunate cases the doctor’s motto of, “First, do no harm” may have been unintentionally broken. Humiliating encounters where the hair puller has been poked and prodded rather than talked to, or told they have a hopeless disorder, or told they should “just stop” are horrifyingly frequent.
Or worse yet, told they were “mutilating” themselves because of some deep-seated problem. Also too common is a history of ineffective treatments-like being told to vacuum after pulling or to snap a rubber band; making it hard to believe that any professional has something to offer.
Failure of one’s own attempts to stop, such as taping fingers or making New Year’s resolutions, can create a feeling of hopelessness about anything helping on a behavioral level, and may cause a profound sense of incompetence to personally make a change. Starting over with experienced, sympathetic professional help and believing one can get better may simply take a leap of faith-it can be helpful to know that many formerly discouraged hair pullers have gotten better with treatment. Even more important is the realization that one can rarely stop hair pulling through will power.
The path to recovery is not the one already walked-not even necessarily the one appearing to be the most direct and available. When faced with a brick wall, brute force is generally not effective in getting to the other side. Finding a toehold to climb over, a hidden door, or even taking it down brick by brick, however, will work. The saying that “there is more than one way to skin a cat” is relevant in treatment of Trichotillomania. There really is another way to work through a problem, even if the method isn’t immediately evident at the outset of treatment.
Anger: Hair pullers’ initial reaction to finding out that there is a name for this disorder and that they are not alone is most often relief. But this can be quickly followed by anger. Anger that they’ve had to suffer for decades with this disorder and never got any help. Or anger as part of the grieving for the losses endured from their disorder. Elizabeth Kubler-Ross has looked at stages of grieving which are cyclical and include anger, sadness, and acceptance. The hair puller may ask, “Why me? What did I do to deserve this? Why should I have to suffer like this?” And the corollary: “It’s not fair-why should I have to do so much work to recover?”
In order to recover, one needs to recognize the true basis of his or her anger, if present, and identify those feelings as related to the grieving thus placing them in the right place as opposed to being directed at their therapist or his- or herself. Acceptance of having Trichotillomania, with all its components, is a necessary part of getting started in treatment. There may be times of anger or frustration during the process of restoration and each time this happens, the identifying process bears repeating.
Timing: Like every other endeavor or phase of life, there is an important matter of timing; of being ready and being in a situation which allows the time and opportunity to start recovery. If one is preoccupied with an ill family member, has a newborn baby, or is facing bankruptcy, for instance-now may not be the time to get started on treatment for Trichotillomania. Accepting this fact and waiting to get started until finding a better time is crucial.
Even after starting on the path to recovery, there will be times that the changes are overwhelming and require time to process and/or get used to. Allowing one’s self to recognize that plateaus and set-backs are simply messages revealing that something difficult needs to be dealt with-rather than evidence of inferiority and failure-allow the possibility of continued growth. The snail does get there, too…
Feelings of unworthiness
If one’s car breaks down, he or she will unquestioningly spend $2,000 to fix it. One will beg, borrow, or steal, if they have to, because it’s a necessity. I have seen loving pet owners spend hundreds or thousands of dollars getting medical care for their dog, cat, or parrot but are unwilling to put the resources into their own treatment for Trichotillomania. Underneath this resistance to take time and resources for one’s self is, in part, that despite what they have read or been told, they are still blaming themselves for being a hair puller. Consequently their pet is treated as more valuable than themselves!
For some, the reluctance is part of being a responsible family member, often a woman, whose children, parents, and husband “must” automatically be put first. At the Pioneer Clinic we often hear, in regards to considering participation in our intensive treatment program where we require six days out of a patient’s life, “My husband would never let me go and leave him with the kids” or, “My boss would never let me have a medical or even an unpaid leave…”
Recovery does not require strength of character, will-power or saintliness. It does require an investment of time, persistence and usually money. Every hair puller deserves all the resources and support they can muster and are entitled to ask for them.
Association of hair pulling with other problems: Individualized behavioral techniques may initially be very helpful only to have other issues intervene in the process. Sexuality and sexual abuse, for instance, may be brought to light such as in one of our patients who, having been sexually abused by her older brother, was threatened with telling her parents that she was pulling out her hair.
Her shame about her hair pulling surpassed even the incest, yet she realized she needed to deal with the sexual abuse before she could continue with her Trichotillomania treatment. Like many other hair pullers, she took a needed break from her treatment program in order to engage in individual therapy regarding the interfering problem.
Older adolescents and younger adults (and some older adults, too) find they have to emancipate themselves from the control or influence of their parents. Agreeing to perform techniques to help stop hair pulling may provoke an internal rebellion against the “parent” which may take many forms. Therapists and doctors as well as the adult side of one’s self may, for instance, be unconsciously treated as a critical or punitive parent resulting in failure to do homework or resistance to taking medication.
Many pullers have similar entwining of their hair pulling with other serious psychological issues so that separating them and dealing with them individually (whether concurrently or sequentially) is required for any progress to be made.
Fear of the loss of identity
Even if the hair puller’s self-perception is that of a defective person and therefore distressing, it is hard to let go of-and harder for some than letting go of the hair pulling itself. The familiarity of this painful self-image may make it easier to maintain than creating the tidal waves resulting from a shift to a sense of personal healthfulness and wholeness.
Needless to say, one’s sense of identity not only has deep roots, but has far-reaching consequences as well. A person’s choice of friends, schooling, occupation, and mate have everything to do with his or her sense of self and, in turn, those choices help shape one’s identity.
So many relationships and aspects of personality may have been formed around one’s hair pulling that to remove the core of “self” that is layered over the behavior may leave one feeling like he or she is trying to walk across a quicksand of change. The changes that will have to occur in order to recover may feel as unfamiliar as moving to a different country: never to return “home” to that familiar space of being alone in a room and pulling.
The very limitations caused by Trichotillomania may actually feel comfortable, particularly when they have been a part of adolescent and early adult development. If, for instance, adolescent hair pullers failed to form a sense of sexual attractiveness, the thought of dating with all its exposure of vulnerabilities and complicated, delicate rituals may feel overwhelming. Putting off the next stage in any delayed phase of growth by relapsing into pulling may be a lot easier by comparison.
There is an intense and extensive repercussion of changing that identity, and the resistance to one’s recovery can come not only from within, but from sources outside one’s self. In choosing friends and mates, people typically choose others of similar overall “desirability.” (This fact, although difficult sometimes to acknowledge, has been determined by research psychologists.) A hair puller with very low self-esteem, although probably considered more desirable than he or she rates his-or herself, often makes choices of defective people (or others with a poor self-image) to form a “balance” in the relationship.
A move towards recovery may disrupt the delicate balance of the relationship by creating a reaction of fear or anger, even abuse, by the friend or partner who may feel he or she could be left behind. They may try to escalate the hair puller’s sense of inferiority to stay safe from the threat of change. Or they may sabotage efforts towards recovery in a number of ways such as minimizing the importance of the problem to the hair puller of becoming extra-critical in a supposed attempt to “help” the hair puller to remember to stop. If the fear behind the behavior is understood by the hair puller, he or she can reassure their partner that they are loved, worthy, and will not be abandoned.
Unfortunately, if the choice of a psychologically unhealthy friend or partner is made to balance the flaw of hair pulling, a destructive relationship may have be abandoned, which, of course, is never easy, and creates new stresses to contend with. Again, if there is awareness that the threat of change is undermining one’s motivation to recover, energy can be appropriately focused on getting support for making that change.
A surprising source of resistance to change in identity I have occasionally seen coming from involvement in a support group for hair pullers. Trichotillomania support groups are helpful from the standpoint of ending much of the hair puller’s sense of isolation and the enjoyment of being truly understood. The group’s collective self-image is made more positive and shame of the individual is reduced. The participant may, however, fear recovery and possible loss of a sense of belonging in the group because somehow a person who is no longer pulling hair might be viewed as a non-puller instead of a puller-in-recovery.
A hair puller who does not pull hair (even if “white-knuckling” it day by day) grows hair and stops talking regularly of relapses might be viewed as “other.” This seems less likely to occur if the support group is focused on recovery and support of that recovery rather than just being generally supportive of the suffering.
Fear of letting others inside
Allowing others to get close enough to help is often a new experience for the hair puller. No one knows more about the detailed, personal sensations and behavior of this private world. It is hard to imagine that anyone else has something to offer than the hair puller has not already thought of and tried. Although recovery seems synonymous with “getting control” over symptoms, in it there are actuality elements of giving up control.
Letting another person such as a therapist into that very private, personal space of hair pulling and following their suggestions instead of the familiar fighting an internal battle means giving up a very ingrained behavior and mind-set. Keeping others out may have become an essential coping mechanism for many who have not had to ward off the intrusions of a parent or others. Self-sufficiency is often, too, the consequence of the isolation created around Trichotillomania.
Trichotillomania is not a verbal behavior: it involves no words nor communication. The time spent in therapy putting words to it is immensely helpful to putting it into perspective and taking some of the bigger-than-life aspects such as shame and hopelessness away. Words allow the problem to be identified and defined as a finite problem with assailable parts.
One of the great advantages of having a well-trained, perceptive therapist is their ability to delineate the puller’s psychological “blind spots.” Everyone has these gaps in understanding of themselves stemming either from long-standing, rigid ways of viewing things or from unconsciously avoiding seeing things that are personally frightening. The therapist can be helpful not only in assisting the puller to recognize these coping mechanisms or psychological defenses, but provide a place of security from which to challenge them and make changes.
Therapists are not the only ones that the puller needs to let inside to fully heal. True intimacy with others is almost invariably affected when Trichotillomania is present. Once self-acceptance has taken place in the puller he or she can start to express all thoughts and feelings without incapacitating fear and allow another to really know him or her. The language gained in therapy can be helpful in bridging the connection with others.
Although there is no scientific evidence that Trichotillomania is associated with any particular personality, perfectionism appears to be extremely common and often provides a real roadblock to recovery in a number of different ways. One common problem is the false belief that in order to stop pulling, all urges to pull must cease. It is highly unlikely that urges to pull will ever completely vanish.
While one can attempt to decrease urges to a manageable amount (such as through medication or naturally over time with relative abstinence from pulling), the main goal is to manage the urges in a different manner than before. It is sometimes a giant leap in recovery when the hair puller realizes that they don’t have to pull whenever they have the urge.
Another threat to recovery comes when the puller experiences success with not pulling, then has a setback. The perfectionist in them says it is all-or-nothing, so they might as well give up. Virtually everyone successful in recovery from hair pulling has times, perhaps during periods of great stress or illness, some degree of relapse. It is hard for many not to feel that they are starting over again. One hour of pulling can mean the total loss of hard-earned lashes or brows-a bad week may result in a large bare area on one’s scalp.
The amount of hair one has at any given moment is not synonymous with the degree of recovery. It is important to realize that all that has been learned about how to stop pulling is not lost in that hour or week. Each setback is simply a new challenge to be figured out. Recognizing through trial and error that, for instance, premenstrual times are uniquely difficult or that studying for final exams inevitably leads to total loss of control allows one to build upon or add to the techniques learned or medications taken.
Yet another roadblock may come when hair starts to grow back. It is bound to be uneven, asymmetrical, stubbly, gray, or in some other way bothersome to the puller. These hairs are, after all, for many, what triggers the pulling in the first place. The urges then become stronger than ever and the tendency to feel or look at these “wrong” hairs has to be avoided in favor of changing the cognition that drives them in the first place.
A number of techniques individualized for each puller can be used at that time. For instance, a person who craves symmetry may need to practice asymmetry in a number of areas to eventually tolerate asymmetry of hair (especially of eyebrows in many cases.)
Rather than hiding all imperfections as the hair puller generally spends much time doing, practicing appearing deliberately imperfect, and experiencing the real lack of importance this has in life, can be a helpful step. This needs to be done in hierarchical stages with the imperfections least important to the puller shown first and the hardest revelations put at the top end of the list.
Recovery, then, is a complicated process fraught with barriers-hidden or overt, real or imagined. Overall, it requires giving you time, effort, assistance, and forbearance. What does the recovered hair puller look like? A woman or man with imperfect hair, urges to pull, possibly occasional bouts of pulling, who has healthy relationships and a positive self-image and identity as a whole, worthwhile human being.