This week a new blog post came out on Psych Central: “Trichotillomania in Childhood and Adolescence: When Anxiety Becomes Self-Injury.” The article was written by Mihaela Bernard, MA, LCPC, a licensed counselor in Chicago. Normally, I am relatively immune to the stigma, judgment, and bullying that comes from having a disorder that is as misunderstood as compulsive hair pulling. But reading Mihaela's words this morning, gorging myself on my mom’s delicious cranberry sauce left over from Thanksgiving, I found myself nauseated. Not only because Mihaela uses words like “disturbing,” “concerning,” and “embarrassing” to describe trichotillomania, thereby reinforcing the sense of fear and isolation that hair pullers face. Not only because this clinician fails to understand even the most rudimentary components of this disorder, in spite of her seeing numerous trichotillomania patients, and consequently spreading misinformation about an already disparaged condition. But, above all, because this woman is interacting with and treating individuals with trichotillomania.
As someone who spent her childhood among therapists who told me to “just stop” and “quit so I could look pretty again,” I know how frustrating, even traumatizing, it is to seek out treatment from someone who has limited understanding of your behavior. In this article, Mihaela shows that she not only doesn’t understand trichotillomania, but also the basic mechanisms through which mental health conditions develop and persist. In a world where seeking help is a critical, oftentimes exceedingly difficult step for those suffering from mental illness, ignorance such as this is unacceptable.
1. The title. First of all, the implication that trichotillomania is a byproduct of anxiety is an over-simplification that points to a lack of knowledge about hair pulling, but also of mental health as a whole. Trichotillomania is its own discrete, self-contained condition. Anxiety often plays a role in the lives of hair pullers, but that relationship is complex and nuanced, a far cry from the cause and effect model proposed by Mihaela. In fact, much of my hair pulling is not triggered by anxiety at all, but by the polar opposite: boredom. Under-stimulation can also bring on urges to pull—many hair pullers struggle while watching television, talking on the phone, or lying in bed. Hair pulling is a compulsion that, as Dr. Fred Penzel suggests in his book The Hair-Pulling Problem, relates to the body’s need to return to a state of equilibrium. Can anxiety factor into this? Of course. But it is not the only factor, and is certainly not the root cause of the behavior. Like all mental health conditions, trichotillomania is part of a complex web of intersectional forces that bring about various behaviors, thought patterns, and emotions. Hair pulling is not a symptom, but a freestanding disorder.
Mihaela’s designation of trichotillomania as “self-injury” is simply incorrect. There is research that confirms that trichotillomania is non-self-injurious, but I also can corroborate that from personal experience. Self-injury, such as cutting, is an intentional and often highly premeditated act that is done with the intent to inflict hurt. For me, the feelings of pain that my cutting produced allowed me to feel more alive—the wounds themselves served as physical evidence of my own existence, a fact that I questioned in the throes of intense, numbness-inducing depression. My hair pulling, on the other hand, is an unconscious act that arises out of momentary, visceral impulses. Pulling out my hair is not painful. It does not counteract other feelings of pain or numbness. I feel relief when I pull, but not because I have successfully injured myself—I feel relief because the act is physically soothing. Pulling is not meant as self-punishment (it feels too good to serve that role) and it is the consequence of an uncontrollable impulse as intense as the urge to scratch a mosquito bite.
2. Equation between trichotillomania and OCD. “This is very similar to the experience of people who struggle with obsessive compulsive disorder.” The comparison of trichotillomania to OCD is not uncommon. In fact, it’s one of the most typical misrepresentations associated with hair pulling. Here, Mihaela is suggesting that they are similar in the “sense of building pressure or tension” that accompanies the behaviors. But this is misguided. While people with OCD engage in repetitive behaviors (such as compulsive hand washing), they do so in order to avoid an anticipated negative consequence. The behavior itself does not provide calm or relief—rather it makes the sufferer feel that he or she has escaped some sort of harm. Conversely, with trichotillomania, I pull my hair because I feel a sudden urge to do so; this has nothing to do with a conscious desire to relieve my anxiety or fear. The accompanying relief comes from the feeling of the act itself, not the sense that I have dodged negative outcomes.
3. Demeaning language. Mihaela writes that most people end up in treatment after their peers, teachers, or friends express concern about their behavior. This, in turn, provides further embarrassment and anxiety, “adding additional stress to an already anxious mind.” An already anxious mind? I consider my mind to be full, complex, and unique. I experience anxiety at times, just as everyone does. But labeling my mind as ‘anxious’ because I happen to have a complicated and challenging disorder is belittling and downright offensive. It reinforces the otherness of the disorder, feeding into the “me versus you” mentality that is at the core of stigma surrounding mental health. Mihaela then goes on to write, “How do we make sense of this disturbing and concerning symptom in psychoanalytic psychotherapy?” To me, the true question is how to make sense of an article that claims to be supporting those with trichotillomania while it uses language as overtly disparaging as ‘disturbing’ and ‘concerning.’ In a world where shootings and bombings are a daily occurrence, we are hardly at a loss for sources of distressing behavior. Individuals with trichotillomania, a condition that is proven to be highly genetic as well as hugely uncontrollable, suffer from significant social, physical, and emotional wounds, none of which are their fault. The use of judgmental language to describe their struggle is inexcusable, and only reinforces the most debilitating aspect of hair pulling: feelings of shame and isolation.
4. Framing trichotillomania as self-injury. Mihaela writes that, “Trichotillomania is a form of communication that cannot be otherwise put into words. It is an unhealthy and dysfunctional coping mechanisms to handle a stressful, overwhelming or threatening situation.” Trichotillomania is in no way a form of communication. It is not a choice or a form of self-expression, conscious or otherwise. It’s a compulsion, an impulse that feels physical by nature—like I said, similar to the urge to scratch a mosquito bite. I do not pull out my hair to make a statement or to communicate something that ‘cannot be otherwise put into words.’ I use words all the time, and I use them purposefully. I don’t use trichotillomania as a way ‘to handle a stressful, overwhelming or threatening situation.’ I don’t use hair pulling for anything—rather, it uses me. People with trichotillomania do not manipulate their hair pulling as a device to send a particular message. Most of the time, we are not even aware of how we may have been triggered in any particular moment. Rather, we are controlled by the disorder itself; many of us struggle to simply get through our days, overwhelmed by the compulsion to pull. Mihaela incorrectly assumes that trichotillomania involves agency and a purposeful decision to communicate in a particular way. She makes trichotillomania into a self-injury, and, even more, her words suggest that the blame rests with the individual.
5. Condescends hair pullers in the therapeutic relationship. Mihaela concludes her article by describing what she sees as the key responsibilities of a clinician in treating trichotillomania: “to help the client find words for the unspoken experiences that cause the irresistible behavior of hair pulling and replace it with healthier ways to manage the anxiety, fear and overwhelming feelings.” Again, the assumption that wordless experiences ‘cause’ the hair pulling behavior is simply false. There is no neatly defined cause and effect relationship related to hair pulling, or any other mental health disorder for that matter. In my experience, hair pullers have no harder time with expressing themselves than anyone else in this world. Certainly many of us may have had traumatic experiences, and some of those experiences could have contributed to our development of trichotillomania. But most of us are not aware of the complex set of factors that contributed to our hair pulling. Trichotillomania has been linked to genetics and family history, and it is unlikely that one discrete cause will ever be identified.
Treatment of trichotillomania does not consist of a therapist helping an individual ‘find words’ for experiences he or she has had—I wrote a book about the traumatic experiences I’ve had, 75 thousand words of experiences, and I still pull out my hair on a daily basis. Treatment of hair pulling should be highly nuanced, sensitive, and relevant, not grounded in the assumption of a cause and effect psychological relationship, nor the pedantic supposition that the therapist help the patient find an alternative, healthier means of communication—in essence, by saying, “use your words,” as if a hair puller were a petulant child.
I would urge Mihaela to attend one of the Trichotillomania Learning Center’s annual conferences. There, she will find hundreds of complex, beautiful individuals who are bursting with words and a myriad of emotional, physical, and psychological experiences. These people engage in body-focused repetitive behaviors (BFRBs), not as an attempt to injure themselves, but because they feel the overwhelming, uncontrollable compulsion to do so. For all of them, trichotillomania (or their respective form of body-focused repetitive behavior) is its own, self-contained experience. It is not a symptom, nor an effect. It is a disorder, one that threatens to dominate their lives. They have all faced feelings of disparagement, judgment, and isolation, from peers and clinicians alike. People who attend the conferences have discovered, as Mihaela writes of what she hopes to provide as a therapist, a “safe space.”
Perhaps the most disturbing part of Mihaela’s article is that she is not alone. Despite the excellent resources and information provided by organizations such as the Trichotillomania Learning Center*, as well as a growing body of empirically supported scientific research on body-focused repetitive behaviors, we still have clinicians who fail to understand the basic components of these conditions. Not only that, but they are playing an active, if unintentional, role in reinforcing the stigma associated with mental illness. I can only hope that, with the expansion of research initiatives and greater vocalization by the trichotillomania and BFRB community, this trend will begin to change.
*The Scientific Advisory Board of the Trichotillomania Learning Center has put together a comprehensive guide for the treatment of trichotillomania and other body-focused repetitive behaviors. Here’s the link: http://trich.org/dnld/ExpertGuidelines_000.pdf.