For the past seven years I have worked almost exclusively with clients who have trichotillomania (TTM), doing both group and individual psychotherapy. I myself suffered from trich from age 3 to age 28, and have been pull-free for nearly 14 years. I learn new things daily about trichotillomania, but I can say with certainty that what has helped me the most in my practice is the use of an addiction model in treatment.

It is generally recognized that there two different types of addiction-behavioral addictions (i.e., shopping, gambling, internet use addiction) and substance addictions (i.e., alcoholism, drug addiction, food addiction). Behavioral addictions are, simply put, addictions to behaviors that are ultimately self-destructive, but temporarily pleasurable. 

In my view, TTM has many of the characteristics of a behavioral addiction: an overwhelming desire to engage in a self-destructive behavior which offers short-term pleasure or relief of tension; remorse following this behavior, the inability to stop engaging in this behavior despite adverse consequences; and great difficulty in stopping in the "middle," or once the behavior has begun. In addition, the puller appears to experience an altered state of consciousness (often called a "trance state"). It is this altered state, or "escape," that seems to me the primary motive. 

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Trichotillomania has been widely misunderstood by the mental health community. First recognized in medical literature in 1889, TTM was once thought to be an obsessive-compulsive disorder, and treated as such, for the most part unsuccessfully. Since 1994, TTM had been recognized as an "impulse control disorder," as described in the current edition of the Diagnostic and Statistical Manual of Psychiatric Disorders (1994). While an impulse control disorder is not considered the same as an addiction, difficulty controlling self-destructive impulses is the hallmark of addiction.

How else has trich been misidentified? In a popular book about self-mutilation ("A Bright Red Scream"), author Marilee Strong, quite erroneously, in my opinion, cites trich as a form of "compulsive self-injury," comparable to cutting (1998, p.27). Yet most experts on trich agree that cutting and hair pulling are not the same. In fact, Strong states that over 70 percent of cutters were sexually and/or physically abused in childhood. This is far from the case with trichotillomania patients, in whom the incidence of abuse appears to parallel that of the general population*. (*this is anecdotal, but is certainly the case in my practice.)

So-most professionals who work regularly with trich do agree that trich is not OCD, nor is it comparable to cutting. So we know what it's not. But what is it? I've suggested it's similar to a behavioral addiction, but that's only an opinion. There are many theories out there.

Recent empirical studies have identified a genetic component to TTM in mice, suggesting, though certainly not proving, TTM has a genetic component in humans. If true, this information can be important and helpful, but possibly upsetting as well. The upside is that it removes "blame" for this condition from the equation, as well as the erroneous concept that pullers are "crazy." The seeming downside is: If it is genetic, perhaps there is no hope for recovery (unless a "miracle" drug is found). As someone who's watched many people recover, and who's been pull-free myself for many years without such a drug, I must disagree.

This is where I find it most helpful to view TTM as an addiction, and why I feel treating it as such provides a powerful context for recovery. Look at alcoholism. One of the most well-known addictions in our culture, alcoholism, puts the addict in an altered state, allowing him or her to temporarily escape feelings. Alcoholism is undisputedly genetic, and the gene for alcoholism has long since been identified. There is also no dispute that alcoholics can, and many do, stop drinking. Further, despite the genetic predisposition to alcoholism, it is not "cured" with medication. In fact, it is not "cured," at all; rather, people who are sober are still considered to be alcoholics in recovery, even if they don't take a drink the rest of their lives. It may also be helpful to consider people with TTM who stop pulling not as "cured," but as in recovery. 

In the early 1900s, alcoholism was considered a hopeless condition. Once a person became alcoholic, doctors despaired of ever being able to help them. In fact, many alcoholics were committed to asylums for the remainder of their lives. In the 1930s, however, Bill Wilson founded Alcoholics Anonymous, a method of recovery primarily spiritual in nature. AA is now a worldwide organization, and numerous studies attest that it is the single most effective treatment for alcoholism. 

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Not surprisingly, it is quite common for medical doctors to refer their clients to AA. And yet, AA is an organization which suggests, among other things, the use of meditation and prayer, suggestions that would normally be unconventional in the practice of medicine. Perhaps, then, treatment for trich may not be found in a pill, but rather, in the sort of inner work and focus AA encourages in its members. 

One other well-known aspect of addiction is the concept that once one begins engaging in the behavior or substance use, the "addictive mechanism" gets tripped, making it much harder to stop in the "middle," as opposed to before beginning at all. One of the most popular slogans in AA is that in recovery, "you just don't take the first drink." The idea is, it's the first drink, not the third or tenth, that is the real problem. 

For those with TTM, there is a similar action at work. Once pulling has begun, the action creates a seemingly irresistible urge that makes it quite hard (though not impossible) to stop. Since pullers frequently begin pulling unconsciously (watching TV, talking on the phone, reading, working at the computer, car trips), they often end up pulling out the "first hair" without awareness. I often say, for people with trich, trying to stop pulling is akin to an alcoholic trying to stop drinking if she had a glass of scotch permanently affixed to her hand. This is why I believe working on awareness is almost always the first step in recovery. 

If your pulling often begins unconsciously, one of the most helpful things you can do is to learn about "mindfulness" ("Miracle of Mindfulness" by Nobel Peace Prize-winner Thich Nhat Hanh is a book I always recommend for this purpose.). Mindfulness is a way of becoming more present in one's daily life, and less pulled to and fro by what mindfulness teachers refer to as "monkey mind." Monkey mind simply denotes the busyness of our minds, and the way we get so caught up in regrets of the past and fear of the future, we forget about the present almost entirely. Learning to be more present in one's life often will lead to learning to be more present in those moments prior to pulling. However, it takes work and it takes practice. 

Once you are able to be aware of the urge to pull before actually pulling, you may experience something many, many pullers find out of reach: A feeling of having a "choice." And while I know well the feeling of being at the mercy of TTM and having no choice, I also know how powerless that left me feeling. To get to that feeling of choice, requires many things: learning to be more present or "mindful," learning to tolerate, rather than push away, painful feelings, a greater sense of self-acceptance, and the letting go of shame and self-blame. Choice gives a puller a feeling of empowerment, and such empowerment will allow you to be your best ally in recovery, as opposed to your greatest critic.

All addictions have one essential thing in common: They provide an "escape." The escape may be from unhappy life circumstances, feelings of anxiety or depression, feelings of stress, feelings of emptiness, feelings of loneliness, or, for some people, simply from any intense feelings at all. From my observation, for many people, hairpulling provides a level of self-soothing, or, at the least, a short-term break from being present, and addressing what's really going on in one's life.

Often people ask me, What can I "replace" hairpulling with? And certainly many pullers find things such as knitting, painting, Koosh balls, and other such activities involving the hands, to be helpful, especially children. And for children, such things may "do the trick," so to speak. If you find anything like that to be helpful, by all means, do it! In my view, however, what ultimately needs to happen for long-term recovery is to replace pulling with is the ability to "tolerate" what you may consider "unacceptable" emotions (anger, grief, excitement), and an "internal" ability to self-soothe. The latter may entail the development of an inner voice that is similar to a supportive and loving parent, a "voice" that challenges your inner critic, and calms you through experiences of fear, rejection, and any other painful or scary feelings.

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Something many pullers (and certain other types of addicts) have in common is perfectionism, and this truly gets in the way of recovery. It's hard to say which comes first, but it's possible some pullers become perfectionists because they believe that if they're perfect at everything they do, their "core flawed nature," including, if not entirely due to, their hair pulling, may be hidden-at least for a time. 

The problem with being a perfectionist, of course, is that by holding such a standard, you are doomed to failure. Human beings aren't perfect, nor should they expect to be. Being a perfectionist, by the way, is quite different from "shooting for the stars," or aiming for excellence, both of which are admirable. Working to do the very best that you can, and appreciating yourself for your efforts, is healthy. Perfectionists, however, tend only to appreciate perfect results, not their extensive efforts, and "beat themselves up" for any minor flaw. 

If you apply perfectionism to recovery from TTM, you can get yourself into trouble. While I see recovery as more than simply the cessation or reduction of hair pulling, certainly those with TTM would like to, at the very least, pull a lot less. However, if only perfection (i.e., zero pulling) will satisfy you, you've got a hard road to hoe, as they say. 

Here's an example: Often people will have two weeks (or two days or two months) of being pull-free, and then one heavy pulling session which results in a great deal of hair loss. For brow and lash pullers, the whole lot can be wiped out in a short period of time. At this point, many people give up, asking, "What's the use?", and suggesting all their former progress has been undone. So they return to pulling again, feeling more hopeless than ever. 

My point is, recovery is a process. If you've had two days of being pull-free, and that hasn't happened since you can remember, having a "slip" does not "wipe that out." At this point, and this is tough, it can no longer be about how much hair you have, but the fact that you are getting through periods of time without pulling. This can never be wiped out. You may have two days of being pull-free (or practically pull-free), and one bad day, then three days of reduced pulling, and another bad day. The key is not to let these slips lessen your belief in yourself, and your commitment to recovery, as they happen to everyone. In fact, they are part of the process. 

It's not unlike trying to eat more healthily. If you have one piece of cake, so be it; this is the time to say, It's OK not to be perfect; I'll do the best I can from here. If, however, you allow that one piece of cake to turn into a week of eating junk food, or even worse, a belief that you can "never" achieve your goal, your perfectionism is actually causing you to fail. If you are working on reducing your pulling, and you have a bad day, that's OK. I don't mean to suggest it feels good, or that you won't be sad or disappointed, but it doesn't mean there's no point in continuing to work on recovery. In the scheme of things, one bad day, or one bad session, or one bad week, won't do you in. Expecting yourself to be perfect, however, just might.

One thing said in AA that I feel applies very much to pullers is that recovery is something that happens "one day at a time." Sometimes one hour or even one minute at a time. You must applaud yourself for those moments, as you've learned to get through a piece of time, a feeling, an experience, without pulling. You are on your way. I always say that that the road to recovery for hair pullers is a one-way highway. Having a slip or a relapse might be like taking an early off-ramp, and sometimes wandering quite far away from the highway before turning back. Once you get back, though, you're still where you were when you left. You cannot "go back," as people who slip often say of themselves. The truth is, the inner work you've done cannot be undone, even if the hair re-growth can. And in the end, it's the inner work that will give you the strength to accept, reduce or stop your pulling entirely, and live a fulfilling, meaningful and productive life.

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