Note: This article is written in honor of the National Trichotillomania Awareness Week. To learn more about Trichotillomania, visit the Trichotillomania Learning Center.
I often tell my colleagues that trichotillomania (hair pulling disorder) represents the wild west of psychological disorders. Unfortunately, it remains one of the least researched and most misunderstood disorders in the DSM. Additionally, there is a lot of pseudoscience, snake oil, and plain old quackery on the internet about the best way to treat it.
In this article, I will highlight what we do know about scientifically supported treatments for trichotillomania. As a disclaimer, this is only an introduction to treating trichotillomania and is not intended to formally train clinicians. Lastly, I will not be reviewing medical treatments for trichotillomania (you can learn more about those here).
Photo by Gregory Parker
The first scientifically based treatment for trichotillomania was Habit Reversal Training (HRT) (Azrin, Nunn, & Frantz, 1980; Duke, Keeley, Geffken, & Storch, 2010). During HRT, individuals become more aware of their hair pulling behavior and practice interrupting the behavior by engaging in incompatible behaviors. For example, people who use their hands to pull from their scalp might practice reaching down towards one’s knees. While HRT has been effective in the treatment of tics and Tourette’s Disorder, it doesn’t work for everyone who has trichotillomania and also has a high rate of relapse. Why? As I described in a previous article, trichotillomania is a very heterogeneous disorder and affects each person differently. A “one size fits all” treatment just won’t work for trichotillomania.
Photo by AlicePopkorn
Recently, researchers have developed more comprehensive approaches to treating trichotillomania. Dr. Charles Mansueto pioneered the Comprehensive Behavioral Model (ComB) for trichotillomania (Mansueto, Stemberger, Thomas, & Golomb, 1997). In ComB, clinicians first understand the function of hair pulling. Does it relieve stress? Does it end boredom? Does it reduce anger and frustration? Next, clinicians identify the main types of hair pulling. Some individuals pull for sensory stimulation (trying to find the hair that feels just right), others due to specific thoughts (I have to get rid of all the grey hairs), etc. Lastly, clinicians create treatments that address all aspects of trichotillomania including emotional regulation (learning more adaptive ways of dealing with stress, anger, boredom), physical habits (using HRT and objects to stop motor behavior), and environmental interventions (covering mirrors, getting rid of tweezers).
While research is underway to evaluate Mansueto’s ComB model, other researchers have found support for this approach to treating trichotillomania. In a recent pilot study, Dr. Nancy Keuthen and her colleagues found that Dialectical Behavior Therapy (DBT) was effective at reducing trichotillomania symptoms for at least 3 months (Keuthen et al., 2010). DBT is a form of cognitive behavior therapy that focuses on learning new ways of regulating one’s emotions. Additionally, in a review of all published scientific treatment studies on trichotillomania, Dr. Michael Walther and his colleagues concluded that behavior therapy (HRT), emotional regulation, and acceptance together represent the most promising treatment for trichotillomania (Walther, Ricketts, Conelea, & Woods, 2010). Furthermore, Dr. Martin Franklin and his colleagues have demonstrated that this comprehensive approach to behavior therapy not only works for adults, but it can help children as young as 7 (Franklin, Edson, & Freeman, 2010).
So what does this all mean? To the best of our scientific knowledge, effective trichotillomania treatment includes three things:
- An increased awareness of when, where, and why hair pulling occurs.
- An effort to control or change hair pulling behavior.
- Emotional regulation training to find alternative ways of dealing with negative feelings.
Here’s how I use these scientific findings to treat trichotillomania.
Photo by Wim Mulder
Before creating a treatment plan, I collaborate with my clients to understand the unique patterns of their hair pulling. This usually includes a 1-2 week record of all hair pulling episodes. I ask each client to record the following information after each hair pulling episode:
- What part of the body was the hair pulled from?
- Where was the person when they pulled their hair?
- What time was it when the person pulled their hair?
- Was an instrument (e.g. tweezers) used to help pull hair?
- What was the person doing while they pulled their hair?
- What was the person feeling before, during, and after the hair pulling?
- What was the person thinking before, during, and after the hair pulling?
- Was anyone else present during the hair pulling?
- What did the person do with their hair after they pulled it? (Sidenote: You’ll want to look out for individuals who swallow their hair, this could lead to a potentially lethal condition known as a trichobezoar and will need immediate medical attention).
Changing Hair Pulling Behavior & Emotional Regulation
Photo by Aimee Quiggle
A key component of Dr. Mansueto’s ComB model is the SCAMP Intervention. SCAMP stands for Sensory, Cognitive, Affective, Motor, and Place. Once my client and I have a firm understanding of the hair pulling behavior, I use the SCAMP Intervention to create a customized treatment plan.
Sensory: For individuals who seek sensory activation on their scalp, we might use brushes, combs, pens, massages, or ice to ease sensations. For hands, individuals can get manicures, use lotions, or file their nails. For the face, bath oils, baths, facial scrubs, or a loofah could be used.
Cognitive: Often specific thoughts can lead to hair pulling. Common thoughts include, “My hair has to look perfect”, “I need to get rid of that blemish”, “I’ll just pull a little”, “I’ve already pulled once, so why try holding back?” Here, individuals practice thinking in more realistic way (e.g. “It’s okay to be imperfect”, “The best way to fix it is to let it heal”, and “A slip-up is not a failure, any progress is helpful”).
Affective: When specific emotions lead one to pull their hair, the best way to address this problem is learn more effective ways of regulating your nervous system. To become more relaxed, individuals can use diaphragmatic (belly) breathing, progressive muscle relaxation, practice meditation, listen to white noise, use a heating pad, drink a warm beverage, take a slow relaxing walk, use an eye/face gel mask, or take a long bath. To address intensity and pain, individuals can stick their fingers in frozen ice cream, put their face in a bowl of ice water, suck on a lemon, snap a rubber band on your wrist, take a cold shower, go for a fast run, or chew a large wad of gum. To deal with boredom, individuals can learn about a topic of interest on the internet, write in a journal, draw, play a musical instrument, read a book, paint, take photographs, do a crossword puzzle, and garden.
Motor: In addition to HRT, physical barriers can often help reduce hair pulling. For example, rubber fingers, band-aids, sleep masks, head wraps, glasses, hats, gloves, thumb braces, and tape can all be used to create barriers to hair pulling. Also, changing the condition of your hair and hands can help (e.g. wetting hair, placing Vaseline on your eyelids/brows, wearing false nails, using hand lotion). Objects such as loud bracelets, elbow braces, and perfume can increase awareness of hair pulling. Fiddling toys can sometimes provide alternatives to hair pulling (e.g. koosh balls, silly putty, clay, knitting). For oral rituals, chewing gum, eating sunflower seeds, chewing raw pasta, chewing a toothpick, and eating gummy bears can help.
Place: Comprehensive interventions should also target the environment in which hair pulling takes place. Individuals can try changing light levels, covering mirrors, getting rid of tweezers (or placing them in the freezer), using sticky notes, keeping certain doors open (to decrease privacy), rearranging furniture, and sitting in different positions.
Monitoring Progress and Revising Treatment
As a client and clinician begin treatment, it’s important to keep a daily log of the hair pulling episodes and the attempted interventions. Some interventions will work right away, others will need to be fine tuned, and some will lose their effectiveness over time. The client and clinician must work together, constantly monitoring and reevaluating the treatment until a plan is developed that fits the needs of the client. This process could take weeks or months. Additionally, since trichotillomania changes as we age, treatments that worked at one phase of life may not work in another.
Advice for Treatment Seekers and Treatment Providers
As you can tell, treating trichotillomania is a complex and long process. It takes a lot of time, courage, and motivation on the part of the individual and a lot of training and experience on the part of the clinician. If you are someone who is suffering from trichotillomania, make sure that your clinician is using scientifically supported treatments. Ask them about the type of treatment they are using. If you don’t hear anything about increasing awareness, changing behaviors, or emotional regulation, their treatment may not be based on science. If they start using personal testimonials and wild theories to backup their treatment, or say their treatment cannot be evaluated by science, run away – they’re probably selling you snake oil.
I recommend using the Trichotillomania Learning Center’s list of health care providers to find individuals trained in scientifically supported treatments. If you are a health care provider wanting to learn more about these treatments, I highly recommend attending a Trichotillomania Learning Center Professional Training Institute and browsing through their clinical resources.
Azrin, N. H., Nunn, R. G., & Frantz, S. E. (1980). Treatment of hair-pulling (trichotillomania): A comparative study of habit reversal and negative practice training. Journal of Behavior Therapy and Experimental Psychiatry, 11, 13-20.
Duke, D., Keeley, M., Geffken, G., & Storch, E. (2010). Trichotillomania: a current review. Clinical Psychology Review, 30, 181-193.
Franklin, M. E., Edson, A. L., & Freeman, J. B. (2010). Behavior therapy for pediatric trichotillomania: Exploring the effects of age on treatment outcome. Child and Adolescent Psychiatry and Mental Health, 4, 18.
Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C., Falkenstein, M., Heekin, M., Jordan, C. A., et al. (2010). Pilot trial of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depression and Anxiety, 27(10), 953-959.
Mansueto, C. S., Townsley-Stemberger, R. M., McCombs-Thomas, A., & Goldfinger-Golomb, R. (1997). Trichotillomania: A comprehensive behavioral model. Clinical Psychology Review, 17, 567-577.
Walther, M. R., Ricketts, E. J., Conelea, C. A., & Woods, D. W. (2010). Recent Advances in the Understanding and Treatment of Trichotillomania. Journal of Cognitive Psychotherapy, 24(1), 46-64.
I will definitely be buying this!
I love this! Thank you.
“It’s not enough,” I whispered to my body.
“We’ve got to push some more.”
“I’m tired,” it replied gasping for air.
“Can’t you see how far we’ve come?”
I looked back for the first time
and saw all the obstacles we’ve jumped
and saw all the battles with depression we’ve won.
I looked at my body
and saw all the fresh wounds dripping with blood.
“I’m sorry,” I muttered to my body.
“I’m sorry for not looking back.”
There was silence.
“It’s okay,” it replied taking a deep breath.
“We live to fight another day.”
And we both slept to the delicate sound of our heart.
I am enough.
I am enough.
I am enough.
Let’s Welcome the Light and Gain a New Perspective on Our Pain
Levi Lusko has used his pain to produce this powerful message. I consider the sword of the spirit (the bible) to be one of my most powerful weapons against the enemy in my battle with bipolar disorder and trichotillomania. In his biblically based book, Levi explains that our suffering is an opportunity for us to to be used like never before.
Our biggest struggles are also the places where we can help others the most. Living through the pain gives us a unique perspective to help others through the same troubles we have. I think one of the biggest problems people have with Christianity is the question of why would a loving God allow such heartache to happen. God does not allow evil, it is part of our sinful world in which we have free will to choose how we live. God hates to see us suffer, but He allows pain to enter our life for a purpose. He uses our pain to help us grow deeper roots in faith and shows you how to help others who are suffering in a similar way. It is a powerful testimony.
Suffering is not an obstacle to you being used by God. It is an opportunity for you to be used like never before.
Levi uses the famous quote from Aaïs Nin, “we don’t see things as they are, we see them as we are” to show that the world is not fixed in some pattern. It can be viewed from many different points and it changes according to who is watching it.
There is a two part sermon series that goes along with this book. I am posting the sermon notes below along with a link to the sermon.
Sword of the Spirit
The Word of God – When we are tempted, the most effective weapon that God has given to us as believers is the sword of the Spirit, which is the Word of God. Jesus modeled this so beautifully during His temptation in the wilderness. When the devil tried temptation after temptation against Him, Jesus used the sword of the Spirit. Jesus spoke the Word of God to Satan. In Luke 4:1-13, Jesus responded, “It is written, ‘You shall worship the Lord God only. Him only you shall serve.” and again brought the Scripture back into context, “It has been said, ‘You shall not tempt the Lord your God.’”
That is why we never give up. Though our bodies are dying, our spirits are being renewed every day. For our present troubles are small and won’t last very long. Yet they produce for us a glory that vastly outweighs them and will last forever! So we don’t look at the troubles we can see now; rather, we fix our gaze on things that cannot be seen. For the things we see now will soon be gone, but the things we cannot see will last forever.
2 Corinthians 4:16-18 NLT
Suffering is not an obstacle to you being used by God, it is an opportunity for you to be used like never before.
How to See through the Eyes of a Lion
- Don’t rely on the naked eye.
- Train for the trial you’re not yet in.
- Let God use your pain.
Start talking. Find a conversation starter for your group.
- Pastor Levi talked about the 1990’s for a second. So, about the 90’s … want them back, or glad they’re gone?
- What did Pastor Levi say that you’re still thinking about?
Start thinking. Ask a thoughtful question.
- Read 2 Corinthians 4:16-18. Do you give more energy and focus to “seen” earthly struggles or “unseen” eternal things?
- Think of one of the worst things that’s happened to you. How does the depth of its impact compare to the length of eternity? How often do you consider eternity?
Start sharing. Choose questions that create openness.
- Read Ephesians 1:17-19. Pastor Levi described how lions’ eyes don’t get more light, they fully use what’s there. What’s blocking light, or hindering your vision?
- Where do you think you’d be weakest in a trial? How will you train for a trial you’re not yet in?
- What God-given insight or opportunity might your eyes be opened to because of pain you’ve experienced?
- Have you seen past pain turn into opportunity? Can you share your story?
Start praying. Be bold, and pray with power.
Heavenly Father, we want to see our pain through Your eyes, through the eyes of a Lion. Help us fix our eyes on the length of eternity and the strength of Your Holy Spirit living in us. Show us how You are turning our pain into power for Your purpose. Amen!
Start doing. Commit to a step and live it out this week.
- Choose a painful moment and ask to see it from God’s perspective. Each day, ask the Holy Spirit to show you the opportunities you now have.
- Ask God to help you see the unseen this week. Make note of any time you sense Him expanding your vision. Come ready to share next week.
- Read Pastor Levi’s Bible Plan: www.go2.lc/eyesofalion
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