Habit Reversal Training for Trichotillomania

The habit of pulling ones hair when bored, tired, or deep in thought is not an uncommon one and just because you pull your hair does not necessarily indicate the presence of a disorder. But according to the Diagnostic and Statistical Manual (DSM5) a diagnosis for trichotillomania or compulsive hair pulling disorder should be considered when the person is unable to stop engaging in the behaviour despite it causing visible hair loss and balding, and functional impairment is evident as a result of the behaviour. This indicates that a bad habit has evolved into a clinical condition and therefore treatment is required.

How are habits formed?

If trichotillomania stems from a habitual behaviour, it stands to reason that one method to overcome hair pulling is to reverse the habit. However in order to do this one first needs to understand how habits are formed. A habit like hair pulling may start off as a once-off behaviour, but positive reinforcement may lead to the person seeking out this reinforcement by repeating the behaviour. For example, the person may be looking to pull out split ends and in the process experiences a feeling of satisfaction, release of tension, or any other number of desirable physical or emotional feelings while pulling the hair. This positively reinforces the behaviour so the next time the individual feels stressed, bored or anxious they may find themselves pulling the hair again to replicate these feelings. This could happen consciously or without the person even being aware. With repetition, the behaviour-reward cycle then leads to the behaviour becoming habituated whereby the person finds themselves either automatically or purposefully engaging in the behaviour in similar circumstances, for example every time they feel anxious.

Out with the old, In with the new

Every habit has three components: a cue (or a trigger for an automatic behaviour to start), a routine (the behaviour itself) and a reward (which is how our brain learns to remember this pattern for the future). Habit Reversal Training (HRT) is a form of cognitive behavioural therapy (CBT) which works on the premise that the most effective way to shift a habit is to diagnose and retain the old cue and reward, and try to change only the routine. So instead of fighting the urge to pull, HRT helps the individual understand what motivates the urge and then find alternative ways of addressing the motivation and adjusting the behaviour so that the more acceptable behaviour replaces the unacceptable one. The idea is that by replacing hair pulling with other behaviours every time you are aware of a hair pulling trigger, eventually this new behaviour will become more habituated .

HRT is defined as a "multicomponent behavioral treatment package originally developed to address a wide variety of repetitive behavior disorders".[, and has four main components:

• Awareness Training

• Development of a Competing Response

• Building Motivation

• Generalization skills

We will take at look at each of these components and what it entails.                             

Awareness Training

An important aspect of habit reversal training is helping the individual become aware of and identify the cues or triggers for hair pulling. In order to do this the person must also be aware of their actual pulling. There are two types of hair pulling – focussed and automatic. Focussed hair pulling is when the individual is aware of the urge to pull and therefore consciously engages in the behaviour. Automatic pulling is when the individual is not aware of the urge to pull and therefore doesn’t realise they have started pulling. Awareness training is used to bring the subconscious pulling into the conscious. Once you have a detailed picture and awareness of the pulling behaviour, you will be better equipped to gain self-control. As such the first step in HRT is usually to describe in detail each time you engage in hair pulling. You will describe where you pull, when you pull, for how long, how you pull, and whether or not you use tools. You will also describe the context and environment where pulling generally occurs, e.g. in the bathroom, while watching TV, etc, and what feelings or thoughts are usually experienced just prior to pulling. These are the vulnerable contexts, warning signs and urges signalling that pulling is likely to occur. Some people find this step very distressing, sometimes even leading to increased pulling. However it is an important step before progress can be made.

Competing Responses

Once the individual has gained a thorough understanding of their pulling, the next stage in HRT is the development of a competing response. A competing response is essentially an alternate behaviour to pulling in response to the urge to pull, but that also makes pulling difficult. For example every time the person is aware of the urge to pull they might put their hands in their pockets until the urge passes. This then prevents the use of the hands to pull hair. However the competing response also needs to provide a similar reward to hair pulling. This may involve using a fiddle toy like a stress ball or a piece of jewellery, or gripping onto an object for the sensory input. The choice of competing response differs for everyone and it is during HRT that you will explore what works best for you.

Building Motivation

Replacing hair pulling with a competing response is not easy and requires practice, practice, practice! It can be very discouraging when results are slow. Thus it is important that the person is encouraged and motivated to continue to practice until the new behaviours replace the old. One way the therapist might help you stay motivated is to help you examine the costs of hair pulling and the gains you will achieve if it is reduced or stopped. You will be asked questions like: what is hair pulling taking away from you, what can you gain if you stopped, and what else in your life gives you positive rewards.

Generalization of New Skills

As mentioned above the key to successfully replacing hair pulling with your chosen competing response is practice, practice, practice. While you may practice in the safety of therapy, the real test is whether you will be able to successfully implement these strategies in the real world. This stage of HRT is about consolidating what you learn in therapy and applying it into real life situations. For this reason, as with all CBT techniques, the work does not begin and end n the therapist’s office. You will always be given assignments or homework that will be discussed in proceeding sessions.

Is HRT Effective?

Because body-focussed repetitive behaviours like trichotillomania has only recently enjoyed recognition and awareness form the medical and research fraternity, scientific evidence for the effectiveness of various treatments for trichotillomania is sorely lacking. However there are some studies that have examined the use of HRT. One such study found that HRT was about twice as effective as another technique known as negative practice with respect to the average percentage reduction in hair pulling episodes, the number of subjects who stopped hair pulling entirely, and those who stopped almost entirely. In another study, the efficacy ofHRT in a group format for the treatment of trichotillomania was investigated. Post-treatment data indicated decreases in measures of global severity of symptoms, severity of thoughts about hair-pulling, and severity of hair-pulling behaviour, relative to pre-treatment measures. Three of the 5 patients maintained improvement at 1-month follow-up, and 2 patients maintained treatment gains at 6 months. Follow-up scores for all patients continued to be lower than pre-treatment scores.  While the evidence suggests that HRT is effective in reducing hair pulling in trichotillomania, it is beneficial for this method to be used in conjunction with treatments to ensure a more holistic and thus sustainable treatment approach. Information on the other treatment options available for trichotillomania can be found on this site.