Tag Archives: Claudia Miles

Change Your Thinking to Change Your Behavior

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Change Your Thinking, Change Your Behavior

 By Claudia Miles

I have been sharing my view that hair pulling & skin picking are most like “addictions” for many years.  I was not taken seriously by other professionals at first, but in recent years I’ve seen the term used more and more when other professionals talk about Body-Focused Repetitive Disorder (BFRD).  In fact, TTM & Dermatillomaia fit the criteria of addiction quite well. Think about the way we respond to an addiction like substance abuse (food, drink, drugs). We develop a craving, we try to talk ourselves out of it by saying: You don’t really want to drink again, you’ll lose your job. Don’t eat that whole box of cookies, you’ll feel sick and diagusted. Don’t keep pulling your hair out, there won’t be any way to cover it up.

The addict in you rebels against this kind of feedback. You want to do it, and all the consequences you are thinking about happen in the long term. You feel bad NOW. Gaining weight or losing hair happens later. You just want to feel better. So finally you  say, “Screw it. I don’t care about the consequences,” and we block out the fact that we missed work last time we drank, lost custody of our kids, took any number of actions that cause us shame, pain, financial loss or worse. You say, “I don’t care, I had a bad day and I’m going to do it.” Or “It doesn’t matter, I already ruined my hair, I’m already almost bald, That is how we give yourselves permission to pick or pull.

1) (Screw it.) It’s hopeless.
2) I don’t care
3) It doesn’t matter anyway.

And by convincing ourselves for just a few minutes that those lies are true, we rebel against what we really want. We pretend that we “don’t care” about pulling, that we’ve done so much damage it doesn’t matter if we pull or not, and finally we feel so hopeless about the idea of stopping forever, we don’t see the point in stopping NOW. (It’s quite similar to the process of procrastination which is often connected to BFRD behaviors: Denial, Delay (now we’ve waited so long it will never get done), Hopelessness)

Rather than trying to “FORCE” yourself to stop, the key is to understand and change the pattern of addictive thoughts. It doesn’t matter whether you are a picker who is aware that you are about to pick or a puller who has already pulled for ten minutes before you become aware of what you are doing. There will be a moment when you ARE aware of what you are doing and think to yourself: “I don’t care!” This thought comes in response to earlier thoughts like, You “shouldn’t” be doing this OR I can’t believe I’m doing this again. We think “I don’t care!” as a way to tell our inner bully to shut up, leave us alone & let us pull. Because let’s face it, pulling & picking are made less pleasurable when we simultaneously are attempting to shame ourselves for engaging in the behaviors.  (And SHAME does not help one bit, of course.)  So we say to ourselves by way of making the shame stop: I DON’T CARE! (In other words, leave me alone, Bully, I want to pull!)

The problem is we have dis-identified with the real reason we want to stop these behaviors, which is not that they are morally wrong or that we “shouldn’t” do them. Rather, it upsets us *THAT* we do them. And it is crucial to acknowledge that, but at the same time, not shame ourselves.

Here’s what I mean. See if you can become aware when you start to think to yourself: I don’t care! Once you do, apply what Mindfulness practice teaches us is the “observer” within and “note” the thought.

You: I don’t care
The Observer (You): Ah, there’s that addictive thought. Telling me I don’t care. Giving me permission to pull.

The problem is, you DO care. You care very much. If you didn’t, you sure as heck wouldn’t be reading this blog. You just want to forget that fact for a moment, an hour, two hours, so you can go to that familiar (and comforting) sense of “Numbness.”.  So what I’m asking you to do here is this: DO NOT bully or shame yourself into stopping. (What are you DOING?! What’s wrong with you?! You’re “pathetic”!) But DO acknowledge that the behavior is causing you pain. The example I give to my clients is this: Imagine an alcoholic who is living in a one room apt. after having lost his (or her) share of custody with his kids. He has to get sober and stay sober for 6 mos to get the issue revisited. Six months seems like FOREVER. So every night, to numb the pain of not seeing his children, he pulls out a bottle of whisky. He may say, You moron, what are you doing? But he feels compelled to continue. So he takes the pictures of his kids and turns them around. Puts them away. It’s too painful to look at his kids. He’s already “blown it” he thinks.

Now I would tell that guy, Go ahead and drink. But do NOT put away the pics of your kids. At the same time, you don’t get to berate yourself for doing something you feel so compelled to do despite all it has cost you. What you do is this: You look at your kids and think to yourself, wow, this drinking has cost me a lot. And it’s not because I don’t care about my kids cause I do! How powerful this addiction must be if it makes me ignore what truly matters. Now this makes the drinking FAR less enjoyable & shifts this man’s thinking from “I’m shit. I’m a loser.” to “This is a serious problem & it’s costing a lot.” That latter voice we can call the “Supportive Friend.” The friend you can be to yourself. The friend who wants to HELP you, not SHAME you.  It’s a completely different way of relating to the self.

Here’s how it translates for sufferers of TTM or Dermatillomania:

Your Inner Bully (You): Stop pulling you pathetic loser!
BFRB* Addict (You): I had a lousy day. I just don’t CARE right now!
NEW-Observer (You): Ah, there’s the inner addict trying to convince me I don’t care.
NEW-Supportive Friend (You): You know what? That’s not true. I DO care. I care very much.  It causes me  emotional pain to do this. It makes me feel bad about myself. I just want to acknowledge that.

Now at this point, I am not saying that you can (or should) instantly stop. Not at all. I am suggesting that you go ahead and pull or pick, while simultaneously acknowledging that you DO care.   Not that you’re an idiot or weak or pathetic. Rather, that you are a human being who’s desire or urge to do this is so strong that it eclipses the fact that the behavior causes you so much pain. Now that’s a HARD spot to be in, and until you can empathize with yourself, you remain stuck in a cycle of Blame, Shame, Addictive Thought, Numbness, More Shame, Emptiness, Self-Hatred.

Please note that I am suggesting you tell yourself that you DO care, NOT because of hair loss or scarring but because you will feel bad about yourself. That’s very important. We all know how long it takes for hair to grow back or skin to heal. It takes so long it’s hard to feel motivated. That’s why it is crucial you motivate yourself based on how you feel about yourself. That can become your immediate payoff. And when you consider the crippling shame and self-hatred that appears sometime after a pulling or picking session, perhaps you can see that there is another kind of cost to this besides hair loss and skin scars.  And when that can be replaced by actively telling yourself that you made an effort (even if the effort at first is just changing your thoughts), you will become a real support to yourself, a cheerleader, a caring friend and more able to continue on the path of recovery. A bully, a critic, a shaming, finger-wagging inner “bad parent” WILL NOT HELP YOU. That kind of thinking will tear down any efforts you make toward your goal. That kind of thinking SUPPORTS the addiction. And you do not deserve it, as one day you will surely know.

As I said for the “I don’t care” thought, the same goes for “It doesn’t matter,” and “It’s hopeless.” The thought “It doesn’t matter” is generally linked with the fact that you’ve done so much “damage” that it doesn’t matter if you do a little more. It’s the same irrational thinking behind, “I went off my diet and ate some cake! I ‘ruined’ everything. Well, I may as well eat everything in the house.” Because that makes sense, right? You ate an extra 500 calories so you may as well eat 5,000.

First of all, even when you break it down literally, I can tell you that it DOES matter. In the practical physical world, even though you may not see the difference right away, any lessened amount of pulling, (55 minutes and not an hour, 3 hours and not 4) is PROGRESS. And progress is what will help you reach your goal. But going back to my earlier point, it’s about shifting the focus in this moment away from what your hair or skin looks like and acknowledging that the shame and anger toward the self you feel is hurtful. It not only doesn’t help you pull less, it absolutely causes you to pull more. Please hear this: All attempts to attack, shame or SCARE you into less pulling or picking, whether done by you or someone else, do the OPPOSITE. Every “I can’t believe you’re doing that!” “Stop it, you’re making a mess of your face!” “Why can’t you.. STOP doing that??!!” and “What’s WRONG with you!!” will push you FURTHER from your goal. Please stop and think about that. You don’t want to “let yourself off the hook.” You falsely believe that loving yourself or, yes, accepting yourself, even while you are still pulling means you are “giving up” and just accepting this is how it is. That’s just plain wrong! Just like you love your kids even if you don’t love the behavior, just like you accept them (vs. rejecting them) when they make mistakes, so too you must accept yourself. Accepting and loving yourself NO MATTER WHAT is the ONLY way you’ll recover.

So you see, it does matter. New dialogue:

Inner Bully (You): Stop pulling! Stop picking! You’re pathetic.
BFRB* Addict (You): I’ve already messed up my hair (skin) so much it doesn’t matter anyway.
NEW- Observer (You): Ah, there’s the addict trying to snow me into believing it doesn’t matter.
NEW-Supportive Friend (You): You know what, it DOES matter. It matters because how you feel about yourself matters. It matters because  it’s about small steps, and even if your skin or hair won’t shift right away, it will eventually if you take those small steps. And it MATTERS because this pulling or picking makes you feel like shit, and recovery only happens a moment at a time.

That same point must be made when recovery feels hopeless. One can imagine that that’s very much how someone who has 100 or more lbs to lose might feel. Because no matter what one does, change doesn’t come overnight. Also, you cannot stop pulling “FOREVER” all at once. You can only improve a little in each moment. Those moments will add up, and believe me, they can become a total cessation of pulling or picking, or a nearly total cessation of pulling or picking over time. But any efforts you do make must be made for TODAY only. Forever feels too big. Forever feels hopeless. Today (or even “right now”) need not feel hopeless. You will be able to DO today. And it’s ok if you can’t quite do that right now.

Changing the dialogue is the first step. Working on self-acceptance and self-love, letting go of negative reinforcement and focusing on positive reinforcement, that must be done before any other efforts are made.

And, NO, you won’t have to fight the urges forever. If you change your thinking and change your relationship with yourself so you can support yourself and love yourself through the process, the urges will start to subside. Just like with any addiction, the urges and the desire takes time to subside, and once in a while may show up out of the blue. That’s why you’ll need that “Supportive Friend” with you. The part of you that encourages you and believes in you, just as you do for your friends who aren’t you. Imagine if you could be as helpful to yourself as you are to others.

With practice, you will see that making just a little progress on this (which is all you CAN do) will eventually get you where you want to go. Just like a person who needs to lose 100 lbs. Yes, they won’t be where they want to be after a day or a week of progress toward healthy eating. But they will have taken a step. And it’s one step, then another, then another, and then maybe a step or two back. That’s how it goes. If you can find a way to accept that, if you can find a way to encourage yourself based on “progress not perfection” (AA), you CAN recover. If you continue to believe that it’s all at once or nothing, Your inner addict wants you to believe this so you will give in and pull or pick. Your inner bully wants to tell you it’s hopeless. But your inner Supportive Friend knows the truth. It’s one day at a time, one moment at a time, one breath at a time. It’s taking one small step and focusing only on what you can do, not what you cannot. THAT, I can tell you, is one of the most important things to know about the journey of recovery from BFRB*s. The second is, You CAN do it!

*BFRB = Body-Focused Repetitive Behaviors

What Causes the Urge to Pull

Here is another great blog post from Trichotillomania therapist and 20 year pull-free trichster, Claudia Miles (my role model).

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.


You Cannot Stop Pulling Until You Accept that You Cannot Stop Pulling

I am getting a lot of inspiration from Claudia Miles’ Blog  lately. She is a therapist who specializes in BFRBs including trichotillomania. This simple concept has been game changing in my perception of tr  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.


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).


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.


By Claudia Miles

posted 2/7/2016