How do you help yourself when you have a difficult problem such as hair pulling?

For almost 20 years we have been treating hundreds of people, young and old, who struggle with trichotillomania (hair pulling) disorder. But what about the people who can't access a therapist, don't have health insurance, or can't afford treatment? What about those people who are seeing excellent therapists, but the therapists themselves have no experience treating hair pulling? How can we help those people? How can we help these people who want to stop puilling thier hair? These are the questions that we have struggled with for many years. How can we make good treatment accessible to all?

By Sherrie Vavrichek, LCSW, CBCD

Ruth Golomb, LCPC

Behavior Therapy Center of Greater Washington, Silver Spring, MD



Reprinted from InTouch, Issue #47, © 2017

How do you help yourself when you have a difficult problem such as hair pulling?

For almost 20 years we have been treating hundreds of people, young and old, who struggle with trichotillomania. But what about the people who can't access a therapist, don't have health insurance, or can't afford treatment? What about those people who are seeing excellent therapists, but the therapists themselves have no experience treating hair pulling? How can we help those people? These are the questions that we have struggled with for many years. How can we make good treatment accessible to all?



Over the years we have been especially concerned about the needs of children with trich who cannot access professional care. For this reason, we wrote a self-help book that is geared to young people but is also helpful to adults and therapists. The book is called The Hair Pulling "Habit" and You, and is based on the ComB (Comprehensive Behavioral) Model pioneered by Dr. Charles Mansueto. We have also adapted material from our book for self-help workshops for adults, which we call "Help Yourself." This article outlines the information from those workshops. We hope that it will assist you in your efforts to help yourself manage or recover from trich.

Identifying Your Pulling Profile

Just as you are a unique person, so, too, is your pattern of pulling behavior. We believe that the most important first step in the process is identifying--and becoming extremely aware of--the unique combination of factors for you that are involved in leading up to pulling, during pulling, and following pulling. We call this a "pulling profile." Although it may be painful to do so, looking at the what, where, when, how, and why of a pulling episode is an essential part of the recovery process. By thinking like a reporter or scientist, you can begin to think analytically and non-judgmentally about how to understand your trich experience.



Understanding your pulling profile involves recognizing that trich is a multi-dimensional problem that is usually maintained by several factors. These include 1) efforts to meet your sensory needs, 2) responding to internal and external cues that stimulate pulling behaviors, and 3) the experience of feeling like your hands have a mind of their own.

1) Sensory Needs

Remember science way back when? If so, then you may recall that the five senses are primarily the senses of touch, taste, smell, vision, and hearing. Some or all of these senses can be extremely important to someone with trichotillomania. In the tactile realm, for instance, your hands may be needed to seek (or are bothered by) certain sensations, such as coarse, rough, bumpy, or prickly. Or they may seek just the opposite--smooth, fine, or soft sensations. For some people, the pulling sensation relieves discomfort or feels interesting or pleasant. For others, pulling the hair is only the mechanism to attain a hair to "play with," which may feel soothing, calming, and relaxing, or invigorating, stimulating, and exciting. The mouth region, which is rich in nerve endings, may be stimulated by the sensation of biting or swallowing the hair, or by having the hair touched to the skin. Other senses can get involved as well. In some cases, the sound of the "pull" or the visual examination of the hair is what are most interesting and satisfying from a sensory standpoint.



2) Internal and External Cues



The second factor involved in trich is that certain "cues" can provoke--or trigger--pulling behavior. These cues may be emotional, cognitive, or environmental.



Emotional or physiological cues can include emotions such as anger, frustration, indecision, impatience, or even feeling really happy! Other internal states that may lead to pulling are physiologically based and include fatigue, restlessness, or hunger. In these situations, pulling can help a person relax, focus, or feel energized.



Cognitive cues are generally uncomfortable thoughts about imperfection. The "imperfection" might be about your hair or hair growth (or lack thereof). Sometimes hairs may be viewed as too thick, too curly, the wrong color, or out of place. Other times you may attempt to "even things out" or "balance sides" because of uneven regrowth.



Perfectionist thinking may also take place regarding one's inevitably imperfect efforts to manage trich. For instance, some people challenge themselves by saying "I'm not going to pull at all today!" Unfortunately, this sets them up for even more pulling, because if they pull just one hair, then they may think they have "failed." At that point, there may not seem to be any reason to try to control their hair pulling for the rest of that day, and increased pulling, or even pulling "binges," can take place. They may try again the next day, only to be disheartened again. This can become a vicious circle of unrealistic expectations, alternating with giving up or pulling out of frustration.



For some people, pulling can also occur when perfectionist thoughts occur in other areas of life. These may include feelings of imperfection around their levels of competency or self-worth, or their frustrations around life events.



Another kind of cue is environmental. Identifying the locations where you pull, and the activities that you are engaged in during those tempting times, gives important information in understanding your pulling profile. For instance, certain rooms or other places where you engage in specific activities can create temptations to pull hair. Using the computer, talking on the telephone, watching television, reading a book, sitting at a desk at work or school, driving in or sitting in a car, or going to bed, can all cue pulling behavior. These activities and environments have certain things in common. First, they are generally sedentary activities. Secondly, they are situations where it is easy to access your head or face because your posture often includes bent elbows and hands close to your face and head. The bathroom and bedroom create special challenges due to the high degree of privacy, which allows for uninterrupted periods of pulling time, as well as easy access to mirrors and tweezers.



3) When Hands Have a Mind of Their Own



There are times when your hands may seem to have a mind of their own! This may be due to the power of repetition, the strength of urges, or being in what some people describe as a "trance-like" state. In addition, once pulling behavior is well established, it may occur automatically, sometimes without your even noticing what is happening until damage has occurred. At other times, you might be aware that you are pulling, but your hands seem to have their own mission, and you may watch helplessly as your hands do their damage.

Recognizing the Elements of Your Pulling Profile

The above factors can be hard to remember so we use the acronym "Fiddle SHEEP" (Fiddling, Sensory, Hands have a mind of their own, Environmental, Emotional, and Perfectionistic thinking) to help you identify the factors that are involved in maintaining your pulling. Once you have that information, you can then use specific strategies to address each of your unique areas of need.



Complete the questions below to see which areas are the most important in your pulling profile, circling or otherwise indicating the specific ones that apply to you:

I tend to pull....(circle the specifics):

Never/Seldom Sometimes Often Almost always



Fiddling: when my hands need stimulation or are restless, or I want to put something in my mouth



Sensory: because it feels stimulating or calming, looks or sounds interesting, or relieves discomfort at the site of the pulling.



Hands Have a Mind of Their Own: the activity sometimes occurs outside of my full awareness, or my hands pull in spite of my efforts to resist.



Environment: when I am doing certain sedentary activities such as: or I am in certain locations such as the bathroom or bedroom, or:



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Emotions: when I am feeling angry, frustrated, or have other strong emotions, or when I am bored, making a transition from one activity to another, or feel tired or hungry or:



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Perfectionism: when I see or feel hairs that are imperfect or out of place, or to even things out; or when I am disappointed in or frustrated with myself for pulling, or for other reasons such as:

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Strategies That Address Your Unique Needs

Once you identify the major factors, or "triggers" that lead to pulling, you can then develop a menu of strategies to 1) meet your body's needs in other ways, 2) find other ways to respond to thoughts, emotions, and internal cues that trigger pulling behavior, 3) develop techniques for modifying the environment so that you will not be so tempted to pull, and/or 4) find ways to block or prevent pulling.



Take a look at the categories of strategies listed below. Circle or underline the ideas that you think would be most helpful to you, and add any others that you think of that are not listed:



Fiddling: Use a koosh ball, squishy ball, twine, string, knotted floss, sandpaper, a swatch of fuzzy material, a textured pipe cleaner, a textured sponge, a pot scrubber, a mushroom or vegetable brush, a nail brush, a feather "boa," a swatch of silk or soft material, a chenille pipe cleaner, a blanket, "worry beads," a piece of Velcro, silly putty.



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Many textured children's toys will be interesting to play with. Craft stores and kitchen stores are good sources of highly textured, sensory items.



Sensory: Use a make-up brush on your face, a textured sponge to wash your face and brush your eyebrows, a wide-toothed comb or brush, a shampoo that tingles, an ice pack on your head or face, splash your face with cold water, jump in the shower and wet your hair, take a bath, chew gum, suck on a peppermint, chew raw spaghetti, do needlepoint or rug hooking, eat sunflower seeds.



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Think about providing your body with different interesting sensations. Bath and beauty stores can be good sources of this type of product.



Hands Have a Mind of Their Own: Use Band Aids on fingertips, wear light weight gloves or rubber fingertips, put tape over fingertips or an Ace bandage on your elbow (when it bends too much it will be uncomfortable), use hand cream repeatedly so that hands are slightly moist, use non-instant conditioner (it takes about ½ hour), put hair up in a towel, wear a hat, wear a scarf, put Vaseline on eyelids or moisturizer for eyes and lids, wear an eye mask, wear a gel mask that can be heated or cooled.



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Environmental: change where you sit, lower the lights, cover the mirror, put reminder notes in different places ("use your strategies"), use a different bathroom, put your make-up on in a different room



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Emotional: keep a journal, talk with a friend, exercise, write a letter, rehearse what you would like to say, take a yoga class, practice relaxation techniques, practice assertiveness techniques



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Perfectionism: Tolerate imperfection! Remember that you are working on the behavior, not the hair...when your behavior is more under control, your hair will grow. Be nice to yourself.... treat yourself in a friendly, compassionate, and non-judgmental manner. Allow for setbacks. Find ways to help you tolerate your hair growing imperfectly (see the emotional factor section).



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Many people use only one type of strategy at a time. However, since most people pull for multiple reasons at any given time, using one type of strategy alone is almost certain to be unsuccessful. Furthermore, most people pull for DIFFERENT reasons, in DIFFERENT environments, at DIFFERENT times of the day! Therefore, using more than one kind of strategy-- preferably three -- in each trigger situation, will have the best chance of succeeding.

Creating and Using a Weekly Schedule:

Use of a weekly schedule can be extremely important in organizing yourself to use the variety of strategies in order to gain control over trich. It provides feedback, gives visual reminders, and is a motivator. We recommend adapting the following chart to meet your needs:



Trigger Situation (Location and Activity)



Watching TV in the family room



Every time I watch TV:



Sun. Mon. Tu Wed Th Fri Sat



I will wear Band Aids on my finger tips (Hands have a mind of their own)



I will brush my hair with a wide-toothed comb (Sensory)



I will "play with" Velcro (Fiddling)



Add some of your own ideas:



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Important Points to Remember:

1. Trichotillomania is neither simple nor is it just a "habit"; it is a multi-dimensional problem that requires a multi-dimensional approach.



2. In order to be successful in managing your hair pulling, you must fully understand it. (Pulling Profile).



3. When using strategies to help yourself, you MUST USE MORE THAN ONE KIND in any given trigger situation to be successful.



4. Use a weekly chart as a reminder and to help you organize your program.



We hope that you will find this program to be helpful. Trying to work on trich can be overwhelming, frustrating and extremely difficult to do on your own. If you have tried other approaches in the past, you may want to switch to this one now. If you have never used a systematic approach, you may want to set up the entire program at one time, or you may want to try a few suggestions at a time and add to them every few weeks.



Most importantly, we know that dealing with trich is a complicated issue. For those who feel that they are ready to try this on their own, we would like you to take as much or as little as you are comfortable with. As hosts at a dinner party might say, "Please...help yourself!"



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Ruth Goldfinger Golomb, MEd, LCPC, and Sherrie Vavrichek, LCSW, CBCD, are staff therapists at the Behavior Therapy Center of Greater Washington, located in Silver Spring, MD, and are co-authors of the book "The Hair Pulling "Habit" and You". Ruth is also a current member of The TLC Foundation for Body-Focused Repetitive Behaviors' Scientific Advisory Board and co-author of "A Parent Guide to Hair Pulling Disorder: Effective Parenting Strategies for Children with Trichotillomania".

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