When I entered graduate school to earn my master's degree in counseling psychology, I had no idea I'd end up specializing in trichotillomania. This, despite the agonizing reality that I had pulled out my own hair for over 20 years on a daily basis, causing not only bald spots but an increasing sense of shame and self-loathing. No matter what I tried (gloves, bandannas, conditioner, hair cuts, "determination," scathing self-criticism), I couldn't stop. Today, with the exception of a three-month relapse in 1994, I have been pull-free since 1989. 

I have worked with hair pullers for nearly five years now, a group that comprises 80 percent of my practice. I lead four therapy groups for pullers* (one for teens 13 to 18) (*as of 2002), and see many others individually. All my clients are in "recovery," in that they have all taken that all-important first step: They have summoned the courage to admit to another person that they pull out their hair and cannot stop; they have sought help. 
The most meaningful and effective way I've found to work with trich is to conceptualize it as an addiction. This allows people to see that, despite its high price tag, trich offers them pleasure--that a part of them, a needy and wounded part most likely, will have a hard time letting go of this haven, no matter how much they believe they want to. Appearances to the contrary, seeing trich as an addiction brings in the element of choice, something we at first resist, but a concept crucial to the healing process. 

I often suggest to clients that when they are pulling, they take the attitude that they are choosing to pull. Such an awareness can be very empowering. 

The most common definition of addiction is: a pleasurable or self-soothing activity that offers immediate gratification, allows one to escape painful feelings or thoughts, and that one continues to engage in despite adverse consequences. Sound familiar? If so, you may be interested in Gary Zukav's book, "Seat of the Soul'--especially the chapter on addictions. Zukav believes, as I do, that uncovering and facing addictions can be a path to meaningful growth: By facing them directly, by being willing to confront whatever is beneath them--often our greatest fears--we evolve as human beings. This is how I see our "work."

One client who has pulled very little for about six months told me that after a recent painful therapy session, she went home and pulled for two hours straight. The moment she stopped, however, she burst into tears and felt the profound grief she'd wanted to keep at bay. She said later that she had never seen so clearly the connection between pulling and "numbing out." By actually feeling the grief, she was able to move through it She's pulled little since.

"But I pull when I'm not even aware of it," you might protest. "I'm often simply watching TV, talking on the phone or reading, not in the midst of an inner conflict."

That may be true--it was for me, and is for most of my clients. My episodes of pulling can not always be traced so directly to a painful incident or stressful experience, but when I forced myself not to pull, even for a couple days, I felt heightened anxiety, fear or sadness. And when I stopped pulling for good, when I could no longer crawl into the womb-like safety of the pulling trance, fears of abandonment, aloneness, and insecurity had to be dealt with. 

I work with people to uncover and face their fears. If they are willing, I sit with them in their angst, despair and grief. Some, you may be surprised, also must learn to allow themselves self-esteem, success and intimacy, things they never believed they deserved, and which may change their roles with friends, family and in their community. When you play self-sacrificing martyr long enough, people expect you always to say yes to requests. They may become peeved when you don't. 

The need to put one's self first, at least sometimes, seems to me universal among pullers.
"But I don't want to be selfish," you may protest.

Remember, being selfish means (i) always putting one's self first, and never considering others needs; this is not what I'm suggesting. The fact is, never considering your own needs can be just as destructive. How can you be a loving parent, friend, sister and lover if you are always operating at half-mast, feeling resentful, empty and depleted?

Most people want to know WHY they pull. I understand their curiosity. While some medical research--and my own experience--points to a variety of physical factors, I see hair pulling as a more a "soul" problem than a medical one. My own belief, based on my personal and professional experience, is that trich, like alcoholism, is both genetic and physiological, but that this is not WHY we pull anymore than it explains why the alcoholic picks up her first drink. I feel we are born with the predisposition, and a variety of events, some severe, some less so, can trigger it.

Triggers most often happen in childhood. Even those pullers with so-called "normal" childhoods suffer the slights and indignities of growing up (such as adolescence). Others suffer more serious injury such as the death of a parent or sibling at a young age. Some, tragically, are physically or sexually abused, or grew up in alcoholic households. Still others were given the message one way or another, and repeatedly, that they are not living up to parental expectations, and by extension, that they are simply, unlovable. This is a kind of tragedy, too, and is what I see most frequently. Nevertheless, why would hair pulling be a response to any of these things?

Pulling, plain and simple, is an escape hatch. If you've read anything on trich, or have it yourself, you are well aware of "trance-like" pulling. Whether one shuts down or numbs out first, and then begins pulling, or starts pulling and then goes into a "trance," we are clearly dealing with an altered state one. Such a state can shut out parents yelling at each other, being teased at school, or simply feeling so worthless and empty it seems intolerable. For some people--most, in fact--pulling was a best friend in those early years. It allowed you to "go away," when in fact, you couldn't leave. It gave solace. You may even want to thank your pulling for having protected you when you had no other way out.

If you are now an adult, though, you have the power to help yourselves in ways you couldn't then: You can go to therapy and learn to tolerate painful feelings (a fact of life) and also joy; you can learn to love yourselves--whether or not you are pulling; and you can physically leave abusive or unhealthy situations. You can, if need be, reduce contact with your family and create a new one: a network of people who love and support you just as you are.

I actually tell my clients not to worry about pulling when they first enter treatment, a direction they often find shocking. "But if I don't at least try to curb my pulling, I'll pull so much more." Let me tell you how my clients "curb" their pulling. They engage in the most hateful, cruel and nasty self-talk imaginable. After pulling, they tell themselves they are sick and disgusting. They tell themselves they are "pathetic" for not being able to stop, weak, bizarre and grotesque. Can you imagine saying this to someone you dislike, let alone a friend? Such self-abuse creates a vicious cycle that becomes deeply ingrained.
There are two things I tell my clients they will need to do to recover: One is to stop mentally chastising themselves in the way I've described. It takes work, but is possible to forgive one's self and develop compassion for the wounded part of the self that longs for the comfort pulling brings. The second thing is to develop awareness. A formal meditation practice is not necessary, but reading a book such as Thich Nhat Hanh's "Miracle of Mindfulness" will aid you in bringing mindfulness into your daily life. The more you use your breath as a tool to center yourself and bring yourself into the present (if you're feeling regret, you're in the past; if you're worrying, you're in the future), the more likely you are to start becoming aware (i) before you pull. This is the "easiest" time to stop; once you've started pulling, the addiction has been sparked and you're battling the beast. Heightened awareness, thus, is essential.

Though I do see value in behavioral and cognitive techniques, particularly with children, with adults I experience the need to go deeper in the psychological sense. There are often deep feelings of worthlessness and shame that have been ingrained as the result of one's pulling, coupled with childhood issues that may have initially set off the addiction, and these must be dealt with. Replacing pulling behavior with an "alternate" behavior, without doing the inner work, is, in my opinion, like covering over a splinter with a Band-aid™. It works for a while, but eventually you have to get in there and pull that splinter out. And yes, pulling it out can hurt like hell, especially if it's been festering for years. But how else can you truly heal?

The following are what I call my Seven Stages of Healing for (Teen and Adult) Compulsive Hair Pullers. As you'll see, these are not quick fixes, but I hope you find them useful. I also recommend attending any 12-step meeting (such as Alcoholics Anonymous) and mentally substituting "hair pulling" for alcohol. I found the 12-steps enormously helpful in my own recovery as do some of my clients.