Treating trichotillomania
I have treated about a dozen people for Trichotillomania (repeated and “uncontrollable” hair pulling leading to noticeable hair loss) a condition affecting about 1-2% of the population according to the DSM-5. Like most psychologists, I struggle with the ambiguity of the science and knowing if what I am doing is ever really helping anyone. With that said, at this stage and to my full knowledge, I maintain a 100% record for successful trichotillomania treatment. Possibly my limited sample size has been made up of mild to moderate cases, although they included clients reporting multiple years of unsuccessful attempts to curb their hair pulling, some with large bald patches and one who had stopped leaving their house due to embarrassment (which had led to even more habitual hair pulling in the absence of activity and interaction).
Psychological treatment for trichotillomania can be explained in a few minutes:
Deliberately and proactively, reach up and grab a hair follicle, just as you do when you are ordinarily engaging in problematic hair pulling.
Stop at the precise threshold of executing a hair pull.
Stay there. Wait. Watch. Mindfully experience. Sit with the urge to pull. Focus on your body in space including the sensations of your finger-thumb pincer-grip and the follicle as well as the 45-degree angle triangulated between shoulder, elbow, and head. Stay there.
Repeat steps 1-3 (Typically I recommend x2 minutes twice-per-day plus an additional minute anytime one consciously awakens to find themselves engaged in problematic hair pulling).
It works on two fronts:
For people who are conscious of their hair pulling but cannot resist the urge, stopping at the threshold builds control. For people who are unconscious of their hair pulling, holding that position a level of conscious awareness that activates whenever their body positions that way automatically.
In a discipline almost characterised by uncertainty, it is nice have at least one treatment protocol that makes immediate sense, can be explained in a few minutes, and at least in my own experience, is highly efficient. For a parsimony challenge I tried to see how short I could edit down the instructions. I got it to nine words:
Face difficulty on purpose to build skill and awareness.
I like a good heuristic and this nine-word instruction holds up quite well across a range of differing problems. Here are some examples;
Panic attacks
Panic attacks involve a sudden spike of intense fear that self-perpetuates through an escalating, interaction of emotion (fear), physiology (particularly increased heart rate and breath) and thought (e.g. “I’m dying”).
In treatment, panic attack symptoms are deliberately and proactively encountered via interoceptive exposure (such as deliberate hyperventilation or spinning on a chair to evoke dizziness) until the person can develop a more accurate interpretation of their physiological arousal (“I’m not dying, this is nothing.”). Later when any one of the panic-relevant emotion, physiology or thoughts are encountered, they cease to trigger the escalating interaction between all three components.
Tantrums
A typical intervention I will do with children (and occasionally with adults) is “the catastrophising game” (https://www.youtube.com/watch?v=fFDQeUZB7pM). Played in pairs, one person points to an object in the room or says a random word to which the other person must invent a way of segueing this prompt into a catastrophising monologue ending in complete annihilation. It is a lot of fun. The benefit here is because catastrophising cognitions are being created deliberately, we have a chance to develop a familiarity and objectivity towards them which we will hopefully still be conscious to next time we experience automatic catastrophising cognitions.
Relationship breakdown
Arguments typically involve heightened emotions and therefore decreased ability to employ rationality and cognitive-empathy. It therefore becomes almost impossible for a couple to maintain a cooperative stance with one another and negotiate compromise. Unfortunately, most arguments happen automatically meaning the topic of contention is only ever being discussed at exactly the worst possible moment (when both people are emotional). A large portion of relationship counselling is simply the act of deliberately and proactively discussing difficulties at a designated and neutral time.
Arachnophobia (or any anxiety disorder)
Hopefully by now the pattern is starting to make sense. Exposure therapy, sits at the centre of most anxiety treatments and could also be summarised as - facing difficulty on purpose to build skill and awareness. Arachnophobia allows a clean example given; 1. all of us are inevitably going to encounter a spider one day. 2. That time could literally be at any moment. 3. A person who is familiar with spiders will handle that encounter better than a person who is not. In anxiety disorder treatment the objective is more to build skill than awareness, skill being the ability to respond proportionately to danger.
Insomnia
Here I am trying to demonstrate the instruction applied to a less intuitive example. Standard treatment for insomnia involves sleep restriction therapy, whereby a person limits the amount of time they spend in bed, e.g. not going to bed until 1am and fatigue has increased. Here delayed sleep is encountered deliberately and proactively. Eventually, a person’s relationship with their bed and the entire project of sleeping becomes less pressured and stress-inducing.
Obviously, I have not discovered anything new with the nine-word, trichotillomania instruction. A child grasps that it is better to have practiced a thing before having to do it for real. But the instruction has become something of a north-star and continues to surprise me with its application.
Ned Dickeson is a clinical psychologist based in Adelaide, Australia.
This is a short essay and not intended as an adequate explanation for an evidence-based treatment approach, especially given all the nuances that each individual experiences.
I have used AI for artwork, research and proofreading but not for ideas or prose which is entirely my own.
