Hair-pulling, also known as Trichotillomania, is a pattern of behavior that affects many people. It causes them to repeatedly pick at or pull out their hair, and often results in noticeable hair loss and emotional pain. Finding effective treatment is critical. One promising therapeutic approach is DBT, Dialectical Behavior Therapy, a type of behavior therapy that focuses on building skills to manage emotions and behaviors, and to accept pain. In this article, I'll explore how DBT can help treat hair-pulling and provide some practical tips for both patients and therapists.

Understanding Trichotillomania

Trichotillomania is defined by a powerful urge to pull out your hair, often from the eyelashes, scalp, or eyebrows. This can lead to significant hair loss. We’re not talking about a random impulse now and again. People with trichotillomania report the urge to pluck out their hair as a powerful craving, and as a need that feels irresistible. The emotions of shame, guilt, and desperation often come up for people with this condition. It has also been linked to withdrawal or isolation. We don’t have quality data on how common severe hair-pulling is as a behavior. There is one study that looked hair-pulling behavior among college students in the United States. The study estimates that trichotillomania affects 0.6% of the US population. It usually becomes a problem when people are 10-13 years old, and for children it happens about equally across the genders. For adults, it affects women about 4 times as often as men. The condition impacts physical appearance and also has profound psychological impacts, including being linked to anxiety, depression, and low self-esteem.

What is DBT?

DBT, Dialectical Behavior Therapy is a treatment focused on behavior change and acceptance. It was originally developed by Marsha Linehan in the 1990s. Originally it was designed to give people relief from self-harm and the symptoms of borderline personality disorder. Since then, it has been adapted to address a variety of situations, including hair-pulling. DBT works by combining behavioral techniques with concepts from mindfulness and acceptance practices.

 

The core components of DBT are:

1. Mindfulness: Stay present in the moment and be fully aware of your thoughts, feelings, and environment

2. Distress Tolerance: Survive crises and high-stress situations without making them worse or resorting to harmful behaviors

3. Emotion Regulation: Manage the full range of your emotions and understand the messages they convey

4. Interpersonal Effectiveness: Communicate effectively and maintain strong relationships

How DBT Helps with Hair Pulling

Some of the most effective treatments for hair-pullings are habit-reversal training, ACT or acceptance and commitment therapy, and DBT. My training and clinical work is in DBT, so that’s what I’ll be talking about today. For good resources on other treatments, you can read more about treating hair-pulling with ACT and treating it with habit-reversal training.

The reason DBT works for hair-pulling is because it addresses the underlying emotional dysregulation and stress that often trigger the behavior, as well as the hair-pulling itself. Through DBT, you learn to become more aware of your urges, understand what emotions drive these urges, and develop healthier options to cope with the urge.

We have quality research to support the use of DBT for hair-pulling, starting in 2010 with a study done at Massachusetts General Hospital and Harvard Medical School. This study was designed to target “focused” hair pulling, done as a response to stress or crisis, and “automatic” hair pulling, done as a habit without conscious awareness. Participants in the study received months of DBT treatment, combined with strategies from habit reversal training. They significantly reduced both hair-pulling behaviors and the underlying emotional dysregulation that drove this behavior. In fact, when the researchers followed up with them three and then six months later, “all participants were either full or partial responders,” which is quite a feat for a therapy treatment! 

Following this up with more recent research, a study published this year examined the emotional impacts of treating hair-pulling with DBT. The study was called “Examining the Effectiveness of Dialectical Behavior Therapy on Impulsivity, Emotion Regulation, Rumination, and Self-Criticism in Individuals with Trichotillomania.” This research went beyond just whether participants were less likely to pull out their hair following treatment. In fact, they found that “DBT effectively reduces impulsivity, improves emotion regulation, decreases rumination, and lessens self-criticism” for people with hair-pulling.

DBT Techniques for Treating Hair Pulling

Breaking the DBT skills down by the four components described above, we get a thorough rundown of how DBT helps people heal from hair-pulling. I’m providing the basics here for how you can use DBT to treat this problem. If you’d like more personalized info about whether it might help you, you can contact us here at Full Focus Therapy for a free consultation to learn more.

 

Mindfulness Skills

The foundation of DBT is mindfulness, and in particular those skills that help you be fully present. For those of us with hair-pulling, mindfulness helps build awareness of the triggers and urges to pull hair, so that you are in a better position to deal with urges intentionally. One core mindfulness technique is Non-judgmental observation, which helps people notice what thoughts, emotions, and urges come up for them. In the Non-judgment skill, we are careful to avoid attaching any shame or disgust to the things we notice. The cycle of hair-pulling, from first noticing the urge, to giving in to it, to feeling shame, to pulling more as a way to distract from that shame, is interrupted when we can take the shame response out of the equation. And the first step to reducing the attendant shame is to notice the very moment it begins to build, so we can address it right then.

Other helpful skills from the mindfulness module include Mindful breathing and Participation. In Mindful breathing we focus on the breath to anchor ourselves in the present moment. With Participation, we throw ourselves wholeheartedly into a different behavior to distract ourselves. For the Participation skill, we can choose any activity that grips us, from dancing bachata to counting ceiling tiles, in order to anchor ourselves to a different thought or a different urge. 

Emotion Regulation Skills

I spoke above about the role shame plays in keeping you trapped in a cycle of hair-pulling, and the Emotion Regulation module is designed to help you manage that sense of shame, as well as the other emotions that can come up related to this behavior. DBT features a many-layered model of emotions, which gets into so much detail that I think describing it to you would necessitate its own blog post. Suffice it to say, the first step of Emotion Regulation is to get an in-depth understanding of the source and experience of emotions like shame, as well as the behaviors that increase and decrease it. 

The next step in this module is the skill of Opposite Action, which is when you replace the behavior of hair-pulling with a different behavior that meets the same emotional need but in a more helpful way. Problem-solving is a key skill in this grouping as well, as it helps build up your sense of agency, so that you are empowered to actually use the skills and reduce your reliance on hair-pulling. 

Interpersonal Effectiveness Skills

One key part of maintaining your emotional balance is relying on relationships with the key people in your life and your community at large. That’s where the skills of Interpersonal Effectiveness come in, which is the fancy DBT label for the Relationship Skills. Effective communication is vital for finding support and healing. Having a network of support you can depend on is irreplaceable. 

In order to strengthen your relationships, and to build them up in the first place, you need to develop the ability to assert your needs effectively, and balance that with prioritizing the needs of others. Interpersonal effectiveness skills help individuals maintain positive relationships and assert their needs. DEAR MAN (Describe, Express, Assert, Reinforce, stay Mindful, Appear Confident, Negotiate) is one such strategy, that helps people articulate their needs clearly in a way that gets others to listen. Establishing and nurturing supportive relationships can provide encouragement and understanding, two of the protective factors that help keep this behavior urge from returning. 

Distress Tolerance Skills

The last module to go over with you is Distress Tolerance, the set of skills that is essential for managing stress without resorting to hair-pulling. It is possible to endure emotional pain in a healthy way, and that’s what Distress Tolerance is all about. One technique to try is Improving the Moment, which helps you survive the urge moment-to-moment, when it feels the most irresistible. It works by distracting yourself or by connecting back to why you want to stop the behavior. 

Speaking of, one key skill in the Distress Tolerance toolkit is the STOP skill, which helps you ride out impulses and urges without giving in to them. The STOP skill relies on the mindfulness foundation, in that it asks you to observe how intense the urge is, pause in giving in to it, and consider the full landscape of your other options. 

Practical Tips for Clients

Developing a personalized DBT strategy for hair-pulling can be hugely effective. Here are some tips to keep in mind:

1. Track your progress: Track the frequency and intensity of urges, what skills you tried and which ones worked, and what triggered the urge. Keeping track of this data can help you identify patterns and tailor strategies to manage your unique needs.

2. Practice Regularly: The best and most powerful DBT skills are worth nothing if you don’t actually use them. How can you keep yourself motivated to try the skills, when hair-pulling is already effective at reducing your pain and stress in the short term? You might try rewarding yourself each time you use a skill, or finding an accountability partner you can brag to each time you successfully ride out the urge. 

3. Seek Support: Speaking of accountability partners: lean on your community as you navigate these changes. Join support groups or online communities for people who struggle with hair-pulling to share advice or find some solidarity.

Hair-pulling is a challenging habit to overcome, especially considering how it can work well in the short term to help you deal with stress or pain, only to ultimately hurt you in the long term. With the right treatment approach, major improvement is possible. DBT offers one structured, evidence-based method for managing these behaviors by addressing the underlying emotional aspects and the behavior itself. By incorporating skills from the Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness modules, you can develop healthier coping mechanisms and a better quality of life. If you find yourself struggling with hair-pulling, consider exploring DBT as a potential treatment option. Remember, change takes time, and with some serious persistence, recovery is within reach.