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What Cognitive Therapy Can Do for TTM

What Cognitive Therapy Can Do For TTM

By Fred Penzel, Ph.D.

It's not the hair on your head that matters. It's the kind of hair you have inside.

- Gary Shandling

When it comes to the issue of therapy for trichotillomania (TTM), a lot of time is spent discussing behavioral approaches, and how to stop pulling. As Dr. Charles Mansueto likes to point out, TTM and other Body-focused Repetitive Behaviors (BFRBs) have many inputs, and the treatment requires a comprehensive approach that deals with as many of them as possible. These inputs and triggers can include environmental, biological, psychological, and behavioral factors. Obviously, not everyone is affected by the same inputs, nor are they affected in the same ways. There is no one-size-fits-all when it comes to treatment. A good treatment program must be tailored to fit each individual.

One area of input I have frequently encountered among many TTM patients comes from the psychological zone. I am specifically referring to what are known as cognitive issues. By this, I mean how sufferers actually think about themselves, their relationships with others, and their disorder. Some individuals are quite logical and rational about the disorder, seeing it as a dislikable problem to be solved, and not feeling badly about themselves for having the problem in the first place. Others respond by feeling personally devastated, feeling defective, shamed, disfigured, and less than others. This kind of response not only doesn't help, but given the nature of TTM, can only lead to more pulling to relieve the resulting stress and overstimulation it causes. It can also impair your ability to function. I find that for some sufferers, their high levels of emotional distress and low self-image, are tougher problems for them then their actual hair-pulling. A fair number of patients do not date or socialize, do not go to job interviews, avoid athletic activities, and generally avoid anything that would expose their problem. A number of studies have documented the serious negative impact that TTM has had on the lives of sufferers.

These days, we find that problems in this psychological zone are best dealt with through the use of cognitive therapy (CT). It is based upon the theory that emotional disturbances such as anger, anxiety, and depression (non-biological depression) are caused not by other people's actions or by external situations, but rather by the illogical, distorted, or extreme ways we view and interpret these things. Basically, extreme and irrational thinking leads to extreme emotions that may be difficult to live with and control. While it may be true that some TTM sufferers have come to think in unhelpful ways due to poor responses by their families and loved ones, it is also true that we cannot change these other people or get them to make up for the things they may have done or not done. CT teaches people to let go of the past, and to work on changing the one thing they do have control over. That is, their own thinking in the present.

I think there is a lesson to be learned from the fact that not all TTM sufferers allow their hair-pulling to affect their ability to function, nor do they let it get them down. I will often ask patients who are struggling with their own responses to their disorder, "What do you think is the difference between yourself, and those who also have TTM but seem to be successfully dealing with it." They will invariably answer, "I guess these other people must think differently than I do." I have to agree with this. 

I try to teach my patients that everyone has a philosophy (or a view) of things, even if they don't think of it in those terms. These philosophies are made up of many ideas and beliefs, which can often be deeply held for most of a person's life, and can be so well-rehearsed that they come to mind almost automatically. They can be acquired during one's early years, from one's family, one's later experiences, or may be shaped and influenced by an illness itself. A good philosophy helps you to effectively cope with life's inevitable disappointments and problems, while a poor one only tends to worsen things. A good philosophy is generally the product of having logical, and provable ideas about life basically commonsense thinking that leads to sensible and workable choices and solutions to things that can be changed, and the acceptance of things that cannot (as they say in 12-step groups). It also contributes to living a balanced emotional life. Poor philosophies are, unfortunately, all too common. It would appear that we human beings have a natural tendency to think illogically, although we also have the capacity to learn to do better. A poor philosophy usually consists of extreme, illogical beliefs, and leads to poor coping due to unrealistic solutions, childish or grandiose demandingness for things you can never have, and extreme emotional reactions. One very efficient way we create a better philosophy is through the use of cognitive therapy.

I am not saying here that cognitive therapy will work directly on the hair pulling itself, but it can be of help improve the mental stumbling blocks that effect sufferer's functioning, and can help a person to engage in therapy and to persist at it so they can ultimately be successful. Cognitive therapy has been proven to be an effective treatment for depression and anxiety, and can also help those with TTM in these, and in many other indirect ways.

Although there are different schools of cognitive therapy, they are basically all based on the same principles, and work in similar ways. I tend to favor the use of what is known as Rational Emotive Behavior Therapy (REBT), originally developed nearly fifty years ago by the psychologist Dr. Albert Ellis.

CT approaches the treatment of disturbed emotions by teaching people skills in:

  • how to learn to better listen to themselves and spot errors in their own thinking
  • how to then vigorously challenge these extreme and erroneous beliefs and see their flaws
  • how to correct them and through repeated practice, replace them with more moderate, logical, and provable ideas and better self-talk

Those who practice and master these skills are then able to have emotions that are more moderate and appropriate to whatever situations occur. This, in turn, leads to better problem-solving and coping.

There can frequently be personal issues which may have to be treated along with a sufferer's TTM, and which may seriously interfere with their therapy if not dealt with. These issues may involve poor self-image, relationship or family disturbances, career difficulties, anger issues, depression, substance abuse arising from attempts at self-medication, etc. There are numerous sufferers whose lives have been negatively affected by their illness for many years, feeling poorly about having TTM, or also suffering important losses in life because of it. While the behavioral therapy component in comprehensive treatment for TTM can address pulling itself, it cannot do much for these bad feelings and losses. Fortunately, most modern behavioral therapists also practice cognitive therapy as well, and are better referred to as cognitive/behavioral therapists. Through the use of CT, they can provide a talk therapy component for the types of philosophical and emotional issues that the behavioral therapy alone cannot help. Changing your behavior can change the way you think, but conversely, changing your thinking can also modify your behavior. These two therapies complement each other, and add to each other's effectiveness.

In order to treat illogical thinking, it is important to first be able to recognize it. Some typical extreme and irrational beliefs seen among TTM sufferers that really need challenging would include the following:

  • If I cannot control my behavior, I am a weak and worthless reject.
  • I must make perfect progress in treatment, and if I cannot, and end up having slips, I am a weak and worthless person, and will never improve.
  • Because I have damaged my own appearance, I must be defective and crazy.
  • Because I have not been able to control my behavior in the past, I will not be able to do so in the future.
  • Because I am worthless and defective, I do not deserve to recover.
  • As a result of my defective appearance, I will always be undesirable, and no one will ever want to be with me.
  • If my friends/loved ones knew about my behavior, they would think I was crazy and reject me.
  • I hate my behavior and cannot help but get upset and depressed whenever I have to face it.
  • Getting control of this behavior is simply too hard. I will never recover.
  • It's not fair that I have this. It shouldn't be. Life should have treated me better.

When looked at closely, it is clear that none of these ideas makes any sense. Therefore, it's not difficult to see how thinking any of the above thoughts could lead to problems in accepting oneself or one's TTM, much less coming to grips with the problem itself.

In addition to these thoughts about the disorder itself, there are many extreme beliefs that can make things difficult even if the sufferer is able to get themselves into treatment. These would include such ideas as:

  • Recovering from TTM should not be hard for me.
  • Getting recovered should not take long.
  • I should get well perfectly and without slips or setbacks of any kind. If I do have them, it will prove I simply cannot recover.
  • I must have everyone's support and understanding if I am to recover.
  • I cannot simply settle for recovery. I must be absolutely cured.

The flaws in these ideas are obvious, although unfortunately, not to everyone. It is clear to see that because we are all imperfect, fallible human beings, no one recovers instantly or in a matter of days, nor do they do it perfectly,. Also, we cannot always get support and understanding from one and all, since we cannot control them. And yet, people recover in spite of these realities. CT helps sufferers get through the therapy process with realistic expectations toward the process and toward themselves.

A good example of how to dispute and change an illogical belief about TTM would be as follows:

Illogical Belief: Because I have pulled out a lot of my hair, I am a crazy, defective, and worthless person that no one will ever find attractive.

Consequences of holding this belief: I feel angry at myself, and am depressed a lot of the time. I avoid dating and social contacts.


  1. How does pulling out my hair prove that I am crazy? It doesn't. I am a normal person in all other respects, and am not having delusions or hallucinations. My behavior may seem crazy to those who do not understand it, but that doesn't make me crazy. I can conduct other areas of my life in a rational manner.
  2. Where is the evidence that it makes me defective and worthless in my entirety as a human being? There is none. Hair-pulling is just one aspect of the many thousands of things that make up the totality of who I am. I am more than the sum total of the hairs on my body. It does not totally define me as a person and is not my complete identity. Also, it is something I can recover from, so how can something so changeable be used to measure me?
  3. Is there really any proof that no one will ever find me attractive? While I may not look my best at the moment, there is no proof that things will never improve, nor that will anyone will then not find me attractive. I will do what I can for the moment to improve things cosmetically, to look my best until things improve. Also, attractiveness in not simply external. It also has much to do with the person you are and the way you live your life.

New Logical Belief: I really don't like the fact that I pull my hair, and I totally dislike the effect it has on my appearance, but I know that apart from this problem I have, I am in all other respects a normal person. It is a behavior that I do, but it is not my identity as a human being and I can see myself beyond my symptoms. Even if I don't look the way I would like at present, it doesn't mean that I cannot keep working to make things better in the future. I cannot completely control who finds or doesn't find me attractive nor can I predict that I will not improve my appearance in the future. I do not choose to live as a social recluse and can still spend time with friends and even date if I choose. If someone is unable to appreciate my as a person, it is probably someone I wouldn't choose to be with anyway.

Consequences of Holding New, More Logical Beliefs: I would not waste time feeling angry at myself, and would stop making myself depressed over ideas that do not make any sense. I could accept myself as the complex being I am, and stop reducing myself to one characteristic. I could get out more, and perhaps even date if I felt like it. Who knows I might just find someone who understands TTM and appreciates me and accepts me as I am.

One important point. CT can't teach you how to make life perfect or how get everything you want from it, but as mentioned earlier, it can help you to function better, maximize what you are able to get, and help you to accept what you cannot. Along with learning to take responsibility for your own emotions, learning to think and reason logically are crucial to coping with everyday life in a world that often seems anxiety-provoking, unfair, frustrating and disappointing. As much as we would love to live in a world without anxiety, frustration, loss, or disappointment, these things can be tolerated and lived with. 

One further important point. Some people look at this approach and superficially assume that it is telling them to not have feelings. This could not be further from the truth. What CT advocates is having emotions that are in keeping with the situation, and not all out of proportion to it. Extreme thinking will result in extreme emotions. CT tries to convert depression to sadness, anxiety to concern, and anger to frustration. You can live with sadness, concern, and frustration. Anger, anxiety, and depression are a lot more extreme, and much harder to live and function with.

CT can also help with a person's recovery. Recovery can present many challenges beyond treatment. You don't just get recovered from TTM you have to stay recovered. Since it appears that stress tends to worsen the symptoms of TTM (in terms of overstimulation, which generally leads to more pulling), it is obvious that those who cope best with life's inevitable stresses in recovery will be more likely to stay recovered. Beyond the use of specific techniques that get a sufferer well, it is the cognitive therapy that keeps them well.

CT, by itself, cannot do the entire job, but can be of great help together with a comprehensive treatment program that hits the problem from its many different sides. In my estimation, it should be a part of recovery for everyone who needs it. As I have stated, getting recovered isn't just a matter of changing your outward behaviors, it is also a matter of changing your view of things.



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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