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Unconditional Self Acceptance and Trichotillomania
Friday, 15 April 2011 16:42



By Fred Penzel, Ph.D.

TTM is, for a majority of sufferers, a disorder of shame, silent agony, inner grief, and isolation. It is one thing to lose your hair through some outside circumstance you do not appear to control such as alopecia (a disease that causes hair loss), normal pattern baldness, or chemotherapy. These are all extremely dislikable occurrences, but the reason for the hair loss in cases such as these is obvious to all who know the person, and is clearly seen as not being the fault, in any way, of the individual. The individual, too, cannot find any reason to find fault with him or herself. It is something else entirely, to have to admit to having lost your hair because you actually pulled it all out yourself. It seems almost incomprehensible to sufferers and onlookers alike that people who are bright, personable, and who are functioning well in the everyday world could have so little control over such a basic behavior. The obvious result of such a situation is for TTM sufferers to jump to the conclusion that they are weak and defective human beings and to blame themselves, and for others to also see it as their fault in some way. There is obviously less sympathy for someone who appears to have brought their troubles upon themselves, no matter what form they take. 

It is easy to see why so many TTM sufferers feel so stigmatized by their disorder. By stigmatized, we mean walking around feeling as if you are carrying a public mark of shame or disgrace, something like Nathaniel Hawthorne's scarlet letter. The term stigma comes from the ancient Greek, where it meant a mark made by a pointed instrument or a branding iron. In ancient times, this mark was made by cutting the skin, or by branding an individual with a hot iron. It was a sign of shame and could be used to distinguish slaves, outcasts, and criminals. An unfortunate reality is that there is still a stigma that is associated with being a patient and having any type of psychological problem. People in this position are seen as being unable to manage themselves, and in need of repair. This feeling of being blameful, in turn, can easily lead to feeling somehow less than others and also to being different in a negative way. Many walk around believing that there is something fundamentally wrong with them as human beings. There are many with TTM who have lived their whole lives feeling humiliated, defective, and abnormal, as if they were some kind of social outcasts. I have lost count of the number of patients I have heard refer to themselves as "weirdoes," "freaks," or "crazies." They have either labeled themselves as such, or have been encouraged to think about themselves in this way by ignorant, misguided, or cruel family members, acquaintances, or even strangers. I know of many cases where sufferers, as children, were punished, threatened or severely criticized for their inability to stop pulling, or suffered serious ridicule or abuse from schoolmates. There are also many adults who avoid family, social, school, and work situations because they fear what others might think or say. It is not uncommon for people to make all kinds of excuses such as claiming that they have alopecia, allergies, hormonal problems, metabolic conditions, and even chemotherapy for cancer. For those of you with more severe hair pulling who have lived in a continual state of near baldness, or without eyebrows or eyelashes, or have had to live secret lives using wigs, makeup, hats, bandanas, special hair styles, etc., it would be hard to imagine not being stigmatized. 

TTM embodies, for many, not only a feeling that they have lost control over themselves in an important and visible way, but also the feeling of the essential loss of attractiveness. This is true for both women and men alike. Members of both sexes are constantly being exposed to ideal images of beauty and attractiveness in the form of supermodels, actors, and actresses. Also, standards of beauty have risen over the years, and have become even more difficult to attain than in the past. There are giant industries devoted to selling products related to improving one's appearance, and people are constantly being bombarded with advertising designed to make them feel insecure about their appearance. Along with such messages, there is also an emphasis on the idea of "rebuilding" yourself according to some ideal image.

One of the worst aspects of being stigmatized is that it can lead a sufferer to even avoid seeking or participating in treatment. They may feel unworthy of getting well, or may tell themselves that someone so crazy, weak, and worthless can never recover, so why bother? There is an excellent book titled Shame and Guilt that discusses much of the research on these two subjects. In this work, Drs. June Price Tangney and Rhonda L. Dearing relate that shame is an emotion of self-blame, and includes an overall negative self-rating. It is also a self-conscious emotion, with a strong component being the desire to hide or escape. This is obviously worsened by actually having something physical to hide. These authors also report that repeated shaming experiences can gradually wear down a person's self-image. Conversely, they cite research showing that there is a connection between a tendency to feel shame and having a poor self-image. Research has also shown links between shame and depression. I have had patients who, due to feelings of shame and embarrassment about their appearance, have avoided job and school opportunities, chances at close relationships, and even family events such as weddings. I have also had patients who have concealed their hair pulling and hair loss from their spouses, for their entire married lives, sometimes for decades. They have fixed their hair in private, behind locked doors, and only been intimate with their spouses at night, with all the lights turned off and their hair clipped to cover their baldness. They have never gone swimming, ridden in a convertible, gone to a hair salon or a barbershop, sat in an amusement park ride, gone outdoors on a windy day, or participated in any activity that might have revealed bald spots and given away the secret they had always regarded as shameful.

I believe that the most important first step you can take in approaching TTM is by facing your feelings about it and yourself. When treating many TTM sufferers, I put this step before any of the behavioral or medication work because I have found that if you cannot begin to come to grips with your feelings about your general situation, it will be very difficult to find the motivation to see the task of recovery through to the end. I have heard Christina Pearson, the founder of the Trichotillomania Learning Center, say "Recovery from pulling is a side effect of right thinking." There is a lot of truth in that statement. There are numerous TTM sufferers who don't just dislike the symptoms they dislike themselves. TTM is not as easy to conceal as other types of Obsessive-Compulsive Spectrum Disorders. It is not as hidden a problem. Being bald, having large patches of hair missing or having no eyelashes or eyebrows can make for a rather public display. Also, it is not always easy for sufferers to conceal that they have done this to themselves. For this reason, I believe that TTM sufferers, as a group, probably suffer from greater stigmatization than those with many other disorders. I would even go so far as to say that the sufferer's feelings of shame and embarrassment, and their poor self image often require more of an intervention than the hair pulling behavior itself.

Many of those with TTM will be frequently heard to say, "I have low self-esteem." It is almost a mantra. Over the years, I have come to believe that there is something fundamentally wrong with the concept known as self-esteem. In fact, it may even lead to more bad feelings and stigmatization, and any TTM sufferers who wish to achieve some type of emotional well-being will learn to resist the temptation to esteem themselves.

If we take a closer look at the meaning of self-esteem, or self-worth, as some refer to it, it is clear that it must be based upon something. It would seem that according to this way of thinking, you cannot assign value to yourself without a particular reason to do so. What this suggests, is that in order for people to feel good about themselves, they have to look at that which is positive and good about them as people, as opposed to concentrating on the negative. This would mean that self-esteem is conditional, and that it can only exist when a person believes that they have accomplished some type of great personal achievement or that they possess positive traits. This is fine on the surface, but is flawed idea at a deeper level. First of all, those who have pulled out their hair, as well as people with other difficulties, may just not feel that there is actually anything positive about themselves, in terms of either accomplishments or traits. They may be living lives with limited social contact, hating their appearance, and being unable to pursue work, etc. Second, and even more important, self-esteem is really about rating yourself, and the overall concept encourages you to do this, in that if you have done something good, or have special talents or traits, you are entitled to esteem yourself. It really doesn't matter how you rate yourself; the idea that you can rate yourself at all is both unhelpful and illogical. This is where self-esteem, as a concept, really lets you down. People are just too complex to be given any kind of rating that will mean anything. Each individual is made up of thousands of different traits and characteristics. The idea of singling out any one of them, such as hair pulling, and rating your entire self as good or bad because of it, is an absurd idea. 

Another problem with the concept of self-esteem is that it is not permanent. Unless you can accomplish some major feat that changes the world, there are generally very few achievements that will allow you to feel a permanent sense of self-worth. The sense of pride that comes with achieving many things soon dims either due to time, being surpassed by the achievements of others, or the disinterest of the public. Therefore, if you believe in self-esteem, you may well be perpetually forced to keep pursuing it, and will never be able to feel content with what you have done. Good examples of this can be drawn from sports stars, famous politicians, or entertainers who feel forced to come out of retirement to attempt new achievements in order to bolster their sense of self-esteem. Another side to this is that even if you are an achieving person with many accomplishments, you will, as a fallible ordinary human being, eventually make a mistake, fail at something, lose an election, have a losing season, get a poor grade, or just have your work surpassed by someone else. If you rate yourself as worthy, or worse yet, better than others based upon your achievements, you will not be able to separate who you are from the things you do. In your eyes, if your achievements are good, then you are good. Unfortunately, there is a flip side to this, meaning that if you do badly or fail, you will be prone to concluding not that your behavior is poor or inadequate in some way, but that you are bad or are a failure as a human being. This can only lead to depression and emotional disturbance. This is the price of pursuing self-esteem.

If you want to be able to rate anything about yourself, then try rating the one thing that can be rated: your own behavior. If you have TTM and rate yourself as bad or defective, the end result will probably be that you will feel depressed or even hate yourself. Also, rating yourself rather than your behavior can only lead to hopelessness. After all, if you rate yourself negatively due to hair pulling, you are essentially giving your total self an overall bad rating, and implying that you are bad in your entirety as a human being. How can you then face the overwhelming task of changing your entire self? If you stick to rating your behavior, and therefore give your hair pulling a bad rating, then it would logically lead you to want to change that particular behavior. This would seem much less of a tall order than having to change your total self. Such a task can only lead you to depression and hopelessness.

There are those TTM sufferers who are able to go about their business out there in the world, and who pursue their own goals regardless of whether or not they have hair. We should not ignore them. There is a lesson to be learned from them. The lesson is, that when a person stops worrying about whether having pulled out their hair, or not looking good cosmetically makes them worthless, they are truly free. It is clear then, that the self-esteem will never help you to achieve your goal of recovery, and that the only logical course is to pursue unconditional self-acceptance (USA). 

What does this mean? It mans accepting yourself without judgment, uncritically, and just as you are, without having to be anything or do anything special. It means seeing yourself as the unique, imperfect, complex, and complete human being you are. If TTM is part of you, it must be accepted, too. 

Yes, even TTM can and must be accepted. TTM is a chronic, biologically-based problem not a psychological problem. It has nothing to do with intelligence or upbringing. You did not ask for it, and you didn't cause it. It's not your fault! For a good deal of the time you have had it, you may not even have known what it was, or that it had a name. Having TTM doesn't mean that you are crazy, defective, or some kind of freak of nature. It does not represent some kind of weakness or failure of moral strength. It doesn't happen to people who are somehow weaker than others or who are less deserving of decent lives. You are more than the sum total of the number of hairs on your body. If others in your society choose to judge you in that way, that is because of their ignorance and insensitivity, and is in no way a reflection upon you. No matter what, you can never be regarded as a defective human being merely because you pull your hair. TTM is, in a way, mostly a problem because society places a value on having hair as a part of being attractive. I like to tell patients that if we lived in a society where it was common to shave your head and cosmetically remove all eyebrows and eyelashes, they wouldn't even be coming for treatment.

So how should you regard yourself? The best way I have ever heard it put was by Patty Perkins-Doyle, Executive Director of the Obsessive-Compulsive Foundation. I once heard her introduce herself as, "I am a person who also happens to have OCD." I suggest that you now say of yourself, "I am a person who also happens to pull their hair."

Fred Penzel, Ph.D. is a licensed psychologist who has been involved in the treatment of TTM, OCD and related disorders since 1982. He is the executive director of Western Suffolk Psychological Services, in Huntington, New York, and is a frequent contributor to In Touch. He sits on the science advisory boards of both the Trichotillomania Learning Center, and the Obsessive-Compulsive Foundation, and can be e-mailed at .

If you would like to read more about what Dr. Penzel has to say about TTM, take a look at his self-help book, "The Hair-Pulling Problem: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2003). You can learn more about it at



Please Note: Then information in this site is presented as a public service to our patients and friends. It is not a substitute for a careful evaluation by a qualified mental health professional.  If you are already under treatment, do not make any changes in your regimen without consulting your doctor.

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