By Nelson Binggeli, PhD
Cognitive Behavioral Therapy (CBT-T) for Trichotillomania is an evidence-based treatment approach. It involves the following elements:
1. Assessment of hair pulling
Assess the onset, duration, types of hair pulling and manipulating behaviors, and frequency.
Assess the effects that hair pulling has on your life. Are there any situations or relationships you avoid because of hair pulling?
Identify the antecedents (e.g., the experiences, thoughts, and emotions that come before the urge to pull hair) and circumstances in which you experience the urge to pull hair.
2. Strengthen your motivation for change
Strengthen your motivation to change and to employ the habit reversal strategies by listing the negative consequences of hair pulling and the advantages of breaking the habit.
3. Monitor your behavior and increase awareness
Employ a self-monitoring record of hair pulling urges and behaviors. This should document the antecedents and circumstances; the length of the episode; the number of hairs pulled; a rating of the strength of the hair-pulling urge by subjective units of distress (SUDs) [see example here]; and associated activities, thoughts, and emotions. Simply monitoring by itself can reduce hair pulling substantially.
Identify the antecedents (e.g., the experiences, thoughts, and emotions that come before the urge to pull hair) and circumstances in which you experience the urge to pull hair.
Identify the preliminary behaviors (e.g., face touching, hair twirling, stroking) and associated activities (e.g., reading, driving, studying) associated with hair pulling. Note the detailed movements involved in pulling out hair along with the substitution of a competing response by observing the behavior in a mirror.
4. Develop and employ competing response(s)
A competing response is a behavior that you can substitute for hair pulling that is substitute that is totally incompatible with the action of pulling hair. Each time you experience the urge to pull hair you are to employ your competing response(s). In the short term, this prevents you from engaging in the habit. In the long term, this is thought to result in changes in your central nervous system as your brain and muscles gradually unlearn their old habits in response to your urges.
A basic competing response is to grasp or clench your hands for 2-3 minutes in response to hair pulling urges or when hair pulling is likely to occur. This response can be used in any situation until the urge to pull has passed.
Additional examples of competing responses are: while sitting in a lecture the pen can be grasped in one hand and the notebook with the other, brushing hair or brows when the scalp tingles, chewing gum to prevent hair chewing, and nibbling or biting on sesame or poppy seeds instead of biting roots. Be creative, but remember that substitute behaviors must be totally incompatible with the action of pulling hair. You can practice the competing response in front of a mirror to demonstrate to yourself that the behavior is inconspicuous.
It also may be helpful to alter aspects of the situation that make it more likely that you experience the urge to pull your hair. Examples may be: sitting up straight as opposed to slouching while doing homework or watching television, or studying at a desk instead of your bed.
5. Learn and employ relaxation techniques
These techniques include diaphragmatic breathing and/or progressive muscle relaxation. These techniques help to reduce antecedent emotional states such as nervousness, tension, and anger. Practicing a competing response breaks the actual habit, while relaxation reduces the urge that triggers the habit. Employ the relaxation technique during the entire 2-3 minute period you are using the competing response.
6. Reinforce the new behaviors
For new habits to last, it is important that they be reinforced, either by yourself or by significant others.
One way to this is: Write down inconveniences, sources of embarrassment, and instances of suffering that come from hair pulling, along with the advantages of control over it, on an index card. Reviewing this index card frequently to stay motivated and also to reward yourself whenever you successfully resist the urge to pull hair. Also engage in any enjoyable activities that were previously avoided because of hair pulling.
7. Correct self-defeating thoughts that may lead to relapse
There is a difference between a lapse and a relapse. You may still occasionally lapse and pull your hair. This does not mean you have relapsed. Relapse occurs when you conclude that you are bound to be chronically afflicted by the habit and that any attempt to change is doomed to failure.
For many people, lapsing into hair pulling is often followed by automatic thoughts such as, "I'll never get better so I might as well pull," or "I'm a failure because I do not have complete control over my behavior." These thoughts are negatively biased and yet become self-fulfilling prophecies.
Rather than engaging in negatively biased thoughts, reflect on the improvement you already have demonstrated and successes in controlling other aspects of life (including new success in control over hair pulling). This will help dismiss feelings of helplessness. Then, return to employing the strategies discussed above.
8. Generalize your successes
After you have learned how to break the habit in one situation (e.g., while studying), make a list of the other situations in which the urge to pull hair is commonly felt. Rank these situations in terms of how difficult you find it to resist the urge. Then, working from the bottom of the hierarchy (the situation in which it is easiest to resist the urge), imagine using the strategies that were previously successful in this new situation. Also, begin deliberately practicing these strategies, beginning with the situation on the bottom of the hierarchy.