Recovering from the Trauma of Trichotillomania
- Hugh Grubb, MA, MF
- Reprinted from In Touch #15 © 1996
- © Trichotillomania Learning Center, Inc. 2008. All Rights Reserved
One of the most destructive consequences of compulsive hair pulling is the prolonged experience of loss of control over one's own actions. The puller not only feels like the victim of an irrational, destructive act, but like the perpetrator of it as well. It is as if one has become a battleground for a horrible and out-of-control struggle. Eventually there develops a sense of oneself as a helpless and exhausted witness to this endlessly repeating trauma.
Trauma can be described as the experience of events that overwhelm one's ability to maintain a sense of integrity, control, and meaning. It can be a single acute experience, or of an accumulation of events that together disrupt what was perceived as the normal state of existence. The inner struggle of the puller clearly becomes over time a chronic trauma. There is conflict instead of integrity, impulsivity instead of self-control, and despair instead of meaning.
When the struggle persists it is the repeated disruption, which then starts to become normal, forcing a change in self-perception. These disrupting experiences do not seem to fit the self-confident image of the person before the trauma. Deep feelings of inadequacy and defectiveness cause or exacerbate confusion, self-doubt and unbearable shame. In the need to make sense of who one is, this becomes the only coherent way of seeing oneself.
In the treatment of trichotillomania, a vital component to long-term emotional health is the resolution of this traumatic loss of belief in personal competence and self-sufficiency. A new way of relating to oneself and to the world is needed, one in which a shared understanding of what has happened can be assimilated, both intellectually and emotionally, so that a more realistic, interdependent sense of oneself in relation to others can develop.
This article will discuss how that can happen. It presents a model of recovery which places emphasis on (1) the trauma caused by recovery itself, (2) the equal importance of cognitive and experiential processes, and (3) the three stages of self-integration which may be achieved drawing on the power of a healing relationship.
The trauma caused by recovery: A serious attempt to control pulling behavior brings about a confrontation with the hair puller's fragile self-confidence and threatens his or her sense of wholeness and integrity: "Which part of me is going to win out this time?" It is a traumatic experience in itself. The deep inner change required to no longer identify with the perpetrator-victim poles of experience means that separation from a familiar and relatively stable, although distressing, world must occur. The pulling has in some way created a balance, like a self-regulating system in which the behavior has played a dependable role. Despite the pain, it is familiar and concrete; known rather than unknown.
The separation required is not only from aspects of the inner world of feelings, thoughts, and impulses, but also from a way of being in the outer world. It requires a change in how one sees oneself and how one imagines one is seen by others, particularly significant others.
As trichotillomania became the "normal" state it forced a closing off of some aspects of the self in relationships. These included many elements that make up self-esteem, such as confidence in sexual attractiveness and psychological health, as well as the willingness to reveal deeply held fears and vulnerabilities. Now an opening to others is needed; the development of attachments in a way that returns some of these lost aspects of the self.
Positive as this goal is, however, considerable sensitivity and patience is required. There will be times of turning away from the goal, when the pace feels too fast. At other times there will be stronger feelings of security and adventurousness. It will help to appreciate the natural rhythm of change, and to be prepared for the self-doubt and self-criticism, which tries to put a stop to it. The doubts and criticism really represent a need for some emotional stocking up, as the changes must be digested.
The equal importance of cognitive and experiential processes: The process of reclaiming oneself through opening to others is both cognitive and experiential. It involves, on the one hand, understanding and the development of a mental model of what is happening and, on the other, shared feelings and interactions, which validate the sense of self, which is emerging. Both the understanding and the feeling are needed, and each interacts with the other.
Insight and understanding form a structure, like the framework of a building that allows experiences to be felt and integrated. This in turn gives the ideas a living, energized reality. It makes them meaningful. The emotional aspects of personal interaction also stimulate thoughts and questions. These lead to more understanding and then to a greater capacity for a wider range of experiences.
Telling one's story to someone else, and experiencing it being taken in and felt and thought about, allows it to be taken back in a different, less defensive way. The story now has less destructiveness, less power to cause feelings of alienation, and is less likely to overwhelm the puller's ability to have the perceptions and thoughts that intuitively guide her towards helping oneself.
An intentional healing relationship, with an individual or group, offers the possibility that the puller's emotional distresses and excitements will be contained as they occur, and then be transformed into bearable and meaningful experiences. Excitement requires just as much containment and management as anxiety, sadness, or anger.
The lack of the ability to contain and manage emotions and impulses can be seen as causing them to be dispersed immediately into the body. The hand goes to the hair instantaneously without any mediating thoughts-as if the cognitive parts of the brain are simply bypassed. The good intentions and admonitions to stop pulling have no influence because in effect they are hard-wired out of the loop. They never have a chance to affect action.
In recovery, the "wiring" is altered so that the impulses do start to go through a thought process. The psychological part of the psychosomatic experience can be recovered. Feelings and impulses (the somatic part) are no longer divorced from perceptions and thoughts about them (the psychological part) and the puller can now have a complete and integrated mind-body experience.
The three stages of self-integration through a healing relationship: The recovery of this integration can be seen as having three parts occurring in a sequence, although new situations can trigger the need for any one of them. The parts correspond roughly to three stages of human development and the way that language is acquired and used in interaction with others. They also each address one of the identifications with perpetrator, victim, and witness.
Stage One-Disarming the Perpetrator: The initial need is for behavioral and cognitive tools which will deflect the impulse to pull into other actions. This is not the time for preventing or avoiding action. "Other actions" include taking one's body out of one location or posture, which trigger the impulse, and putting it in another. Examples would be: leaving the comfortable TV chair, doing something else with the hands, or doing a relaxation exercise, etc. When the impulse is strong it demands action and circumvents attempts to control it. However, it can be delayed until a different action is taken.
This is like the early childhood stage of development in which impulses cannot yet be contained and managed, but can be delayed once they are given a name ("Use your words.") Language at this stage provides a label for the experience. It creates the opportunity to recognize the experience as it happens, pause, and remember the other behavioral options that have been prepared for this situation. This is how keeping a log of situations and feelings leading to (or accompanying) the urge to pull can be effective. These are important elements of the Response Prevention and Exposure treatment modalities.
The role of language at this stage is not to create ways to reflect on the impulse and its accompanying emotions, although that is its role further into the recovery process. The "perpetrator" is not being reformed, but disarmed. When faced with the intensity of primary impulses the puller has greater need of a way to create a delay, a buffer against the perpetrator experience. And it may still be necessary some way into the recovery process, when urges to pull become once again overwhelming because of a new or unexpected trigger.
Stage Two Finding the Voice of the Victim: This stage is about managing emotions. For many people, the act of pulling seems to serve the purpose of regulating their emotional states. Certain feelings and moods are experienced as intolerable and cannot be integrated into their sense of who they are and how they should behave. They have inadequate ways of modulating this energy, or of expressing what it conveys, so that it fits within the bounds of what they see as appropriate behavior. (This is one of the consequences of the traumatizing effect of trichotillomania.) Attempts to deny or repress or disown the experience do not eliminate it. Instead the only outlet available is through direct bodily action. It may then happen that once this physical behavior (pulling) is discovered and becomes associated with some relief from the unendurable dilemma that preceded it, it may become a habit and, eventually, a compulsion.
Somewhat like the experience of a youth learning to find words to express new experiences, which shape his or her identity, language development now creates possibilities for the puller. Describing one's actual experience and developing sensitivity to the changing ways that one is affected by it, one starts to expand the range of what can be felt. This also allows the integration of what is felt into a sense of who one is, which is less narrowly defined by self-limiting attitudes and behaviors. As what was vague now becomes more concrete, the acute aspects of the trauma feel more distant. A renewed self-confidence and enthusiasm for life can begin.
However, this is a hard-won freedom. Finding a way to talk about, and reflect on, things that have felt unendurable means accepting the challenge of them. Yet what we do now know is what frightens us, and what frightens us we try to defend ourselves against. Without the safety and objectivity of a therapeutic environment, some aspects of the traumatic experience may remain sealed behind these defenses and continue to exert an influence outside the reach of awareness. The emotional losses and feelings of inadequacy experienced from the victim position are part of these. They can remain alive and undermine the recovery process until they are mourned in the presence of an empathic listener. (Conceptualizing these feelings as belonging to an "inner child" is often very helpful in finding a voice for the experience.)
In addition, the puller who is in psychotherapy can make use of the relative safety of the interaction with the therapist to become aware of how he or she is continuing to struggle and defend against experiencing certain intolerable thoughts and feelings. This provides an opportunity to actually experience in the here-and-now of the relationship how emotions and impulses that are not assimilated can be dispersed automatically into the body, and how to try managing them differently.
Stage Three-Becoming a Positive Witness: This stage is about the achievement of a tolerable and satisfactory relation with the urge to pull (which may never completely cease.) In this stage, language continues to provide the means to integrate experience, but it also now allows for the ability to reflect on it, to be self-analytical, and to create shared meanings with others. This also occurs in the developmental stage of adulthood. In recovery, it is the generation of changed relationships to self and others. There is a greater sense of the mutual dependency between people and an alternation between the vulnerability of needing to belong and invulnerability of independence.
The alternative to the absence of control over impulses does not necessarily have to be more control over them. Instead it can be the discovery of how to depend on something or someone outside the sphere of control that provides the security and opportunity to behave differently.
Through the stages of recovery from trauma, the object depended on becomes progressively less concrete and more abstract. It begins with substitute physical objects and specific techniques and actions. It then moves to awareness of emotional states and mental concepts that provide a framework for the experience. Finally it becomes something jointly created with others through the acceptance of interdependence.
The role of the witness has now evolved into a significantly more positive force for change. The urge to pull, when it occurs, can be perceived as an indicator of emotional tension or unrealized mental activity. In the absence of other ways to know, pulling reveals disequilibrium or potential in the way one brings one's thoughts and feelings out into the world. As such it provides a clue that the puller can translate into an adaptive response.
Once trichotillomania can be understood this way then the task is no longer to conquer the behavior, but instead to relinquish it. Rather than representing something which alienates the puller from other people, it signals the presence of a shared human experience-the innate desire for, and tendency towards, wholeness, equilibrium, and engagement in authentic relationships with others.
The trauma of chronic compulsivity creates a perception of one's life experience as unintegrated, out of control, and lacking in meaning. I have attempted to present a model of recovery that explicitly addresses this problem. The dialogue of a healing relationship restores integrity through validating the truth of the experience, it calms the fear of loss of control through revealing the security of interdependence and it generates a sense of a world once again made meaningful through discovering the urge to live contained in the urge to pull.
Reference:
Brown, Stephanie. 1994. Alcoholism and trauma: A theoretical overview and comparison. Journal of Psychoactive Drugs 26(4): 345-355.
Hugh Grubb is a psychotherapist specializing in recovery from Obsessive-Compulsive Spectrum Disorders. He is in private practice in Los Gatos and Santa Cruz, California, and can be reached at (408) 395-7592.