Skin Picker Turned OCD Therapist

Danielle Lieb-Foley chimes in on getting out of a pulling episode, fighting your inner voice, and living a happy and fulfilled life with trichotillomania.

How do you advise people to get out of the middle of a pulling episode?

Once you’re able to become aware of the pulling, I challenge you to push pause. To STOP in the middle of an episode can feel incredibly impossible, but pausing can feel doable with the choice to go back and resume.

Pausing can be 5 seconds, 15 seconds, or 5 minutes. It allows time for you to see that 1) you can control your actions for a period of time and 2) you can make a different choice.

Create a mantra (a saying you can say aloud or in your head), make up a pros/cons list, use a Habit [behavior] Blocker, grab a Competing Response (fidget toy for example), or change your environment. If after doing one or all of these things, you choose to go back to pulling your hair, at least you’ve paused it and that is progress. You can build on that. 

How do you advise people to deal with that inner voice that can pop up? You know, that voice that says, "You deserve to feel awful and look ugly because you have no self-control, so keep going as punishment."

 This internal dialogue can be so difficult to challenge. I might ask, “Why do you believe you truly deserve this?” “Why don’t you feel you deserve to feel better?” I’d ask you to “perspective-take”: think about what you would say to a friend who is feeling a similar way. You’d probably come up with beautiful neutral statements.

I then ask, “Why are the rules are different for you?” “Who created these rules?” “Could the rules be changed, and could you perhaps have the same compassion you have for others for yourself?”

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“Could you perhaps have the same compassion you have for others for yourself?”

Is there a type of therapy that is the holy grail for hair pulling or does it depend on the person?

 I’ve been treating BFRB clients for 18 plus years and my first go-to is a specific Cognitive Behavioral Therapy (CBT) called Habit Reversal Training (HRT).  When treating BFRBs, it is so much more than just the pulling/picking.  It includes all that surrounds the behavior like: What triggers the pulling? What are you getting from the pulling? What are your underlying stressors, anxieties, or situations? How can you learn to tolerate not just the urge, but the feelings that the pulling may be numbing you from?

How can we process the shame and other multitude of feelings that can come from trichotillomania? Can we work through the love/hate relationship and then the loss of the behavior if you stop pulling/picking? Treatment is complex but necessary.

From the people you've treated with hair pulling disorder, are any of them free from it and if so, how did they get there?

Yes, some have stopped pulling their hair. Others, have immensely reduced it.

My goal is to treat, not cure. While it might be a possibility to become pick or pull free, I will never promise this to someone because I believe this can set up a huge expectation.

I’d rather have you become aware of triggers, tolerate urges, process/challenge underlying issues or struggles, and have a toolbox of go-to Blockers and Competing responses to better tolerate an urge.

The biggest key to this work is motivation. Also, the willingness to sit through discomfort, feel all the feels, and develop self-compassion and flexibility.  

Some people are afraid to give up pulling their hair because it's such a big part of who they are. How do you advise on dealing with this aspect of letting go?

I’ve had clients who were not ready to let it go and that’s okay. They know I’m here if/when they are ready. Trichotillomania may feel like a big part of you, but there is so much more that you may not have had the chance to explore within yourself due to struggling with hair pulling.

It’s important for you to identify those other areas of your life that trichotillomania is keeping you from and find ways to embark on them.

Create a list of what hair pulling gives you and what it takes away (often the consequences outnumber the pros). When you look at your list, you’re probably able to see that hair pulling really is not worth everything it takes away from your life.

Remind yourself: this is a process. Treating trichotillomania will not just lift and leave you with a black hole of emptiness. As you progress, newer experiences and feelings may start to fill up this space and make your transition a bit easier.

How can people live happy, healthy lives even with severe trichotillomania?

You are not your hair pulling. You are so much more than your habit. Often times, we are our own worst critic. We attempt to mind read, believing that we know what everyone is thinking, seeing, and feeling about us. We do not hold this gift.

Create a list of everything that makes you, YOU. How can you strengthen those parts? Again, perspective-take. How would you advise a friend who is struggling with hair pulling? My hunch is that you’d be encouraging and non-judgmental. Why can’t this apply to you?

Lastly, we can’t control our thoughts or feelings, but we CAN control our behaviors. Sometimes we need to get out and try something, experience the anticipatory anxiety, and see we survived and maybe even enjoyed the experience! As we change our behaviors, our thoughts and feelings will often follow. The more we do this, the greater the chance that we will feel more comfortable living a full, happy, healthy life. 

** Disclaimer: I’m not only a therapist who’s treated body focused repetitive behaviors (BFRBs) for over 18 years, but also, I am a picker myself. I say I am a picker vs. was a picker, because it’s something that can show up in times of stress. But because of my experience and therapy, I know what works for me and I put those methods to use.