Trichotillomania: Therapist Guide: An ACT-enhanced Behavior Therapy Approach Therapist Guide (TREATMENTS THAT WORK) [2 ed.] 9780197670309, 9780197670316, 9780197670330, 019767030X

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Trichotillomania

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TREATMENTS  T H AT W O R K

Editor-​in-​Chief David H. Barlow, PhD

Scientific Advisory Board Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

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T R E AT M E N T S

T H AT W O R K

Trichotillomania An ACT-​Enhanced Behavior Therapy Approach Second Edition

THERAPIST GUIDE

D O U G L A S W. W O O D S M I C H A E L P. T W O H I G

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Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2023 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-​in-​Publication Data Names: Woods, Douglas W., 1971- author. | Twohig, Michael P., author. Title: Trichotillomania : an ACT-enhanced behavior therapy approach therapist guide / Douglas W. Woods, Michael P. Twohig. Description: Second edition. | New York, NY : Oxford University Press, [2023] | Series: Treatments that work | Includes bibliographical references and index. Identifiers: LCCN 2022040678 (print) | LCCN 2022040679 (ebook) | ISBN 9780197670309 (pb) | ISBN 9780197670316 (epub) | ISBN 9780197670330 Subjects: LCSH: Compulsive hair pulling—Treatment. | Acceptance and commitment therapy. | Behavior therapy. Classification: LCC RC569.5.H34 W66 2008 (print) | LCC RC569.5.H34 (ebook) | DDC 616.85/84—dc23/eng/20220912 LC record available at https://lccn.loc.gov/2022040678 LC ebook record available at https://lccn.loc.gov/2022040679 DOI: 10.1093/​med-​psych/​9780197670309.001.0001 9 8 7 6 5 4 3 2 1 Printed by Marquis, Canada

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About

T R E AT M E N T S

T H AT W O R K

Stunning developments in health care have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit but also, perhaps, inducing harm (Barlow, 2010). Other strategies have been proven effective using the best current standards of evidence, resulting in broad-​based recommendations to make these practices more available to the public (McHugh & Barlow, 2010). Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and health care systems and policymakers have decided that the quality of care should improve, that it should be evidence-​based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001, 2015; McHugh & Barlow, 2010). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-​ based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral health care practices and their applicability to individual patients. This series, Treatments ThatWork, is devoted to communicating these exciting new interventions to clinicians on the frontlines of practice. The manuals and workbooks in this series contain step-​by-​step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing ancillary materials that will approximate the supervisory process in

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assisting practitioners in the implementation of these procedures in their practice. In our emerging health care system, the growing consensus is that evidence-​based practice offers the most responsible course of action for the mental health professional. All behavioral health care clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. Trichotillomania (TTM), or hair-​pulling disorder, is a disorder on the obsessive-​compulsive spectrum that can lead to a variety of psychosocial and physical concerns. Acceptance and Commitment Therapy (ACT)-​Enhanced Behavior Therapy for Trichotillomania (AEBT-​T) is a 10-​week behavior therapy program designed to treat adults and youth with TTM. AEBT has been widely tested in multiple studies across various face-​to-​face and telehealth formats. Its results are robust and durable. AEBT-​T is designed to help individuals step out of the struggle with their pulling and pulling-​related urges, and step into a life they value. AEBT-​T combines traditional behavior therapy approaches with Acceptance and Commitment Therapy (ACT) to help patients reduce pulling, increase psychological flexibility, and lead a more fulfilling life. Each chapter contains information about a new skill or concept that will help individuals with TTM overcome their pulling. Now in its second edition, this program will be of great benefit to those wanting to overcome their pulling and lead a more effective, valued life. David H. Barlow, Editor-​in-​Chief Treatments ThatWork Boston, Massachusetts

References Barlow, D. H. (2004). Psychological treatments. American Psychologist, 59, 869–​878. Barlow, D. H. (2010). Negative effects from psychological treatments: A perspective. American Psychologist, 65(2), 13–​20. Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academy Press.

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Institute of Medicine. (2015). Psychosocial interventions for mental and substance use disorders: A framework for establishing evidence-​based standards. National Academies Press. McHugh, R. K., & Barlow, D. H. (2010). Dissemination and implementation of evidence-​based psychological interventions: A review of current efforts. American Psychologist, 65(2), 73–​84.

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Contents

Acknowledgments  xi About the Authors  xiii Contributors  xv Introduction: Introductory Information for Therapists and Assessment  1 Chapter 1 Session 1: Trichotillomania (TTM) Education, Therapy Overview, Expectations, and Assessment of Pulling Triggers  35 Chapter 2 Session 2: Habit Reversal Training (HRT) and Trigger Reduction Strategies  45 Chapter 3 Session 3: Increasing Motivation for Treatment Through Values  57 Chapter 4 Session 4: Can Pulling-​Related Inner Experiences Be Controlled?  65 Chapter 5 Session 5: Acceptance of Pulling-​Related Inner Experiences  77 Chapter 6 Sessions 6 and 7: Defusion from Your Inner Experiences: You Are Not Your Urges to Pull  87 Chapter 7 Session 8: Practicing Acceptance and Commitment Therapy (ACT)  103

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Chapter 8 Session 9: Practicing Acceptance and Commitment Therapy (ACT) and Review of Treatment  113 Chapter 9 Session 10: Review and Relapse Prevention  119 Chapter 10 Modifications for Working with Adolescents  123 Appendix A: Assessment Measures  145 Appendix B: Client Forms, Graphs, and Worksheets  153 Appendix C: Caregiver Handouts  169 References  179

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Acknowledgments

Dr. Woods would like to thank his family, Laurie, Sullivan, Zachary, and Abigail, and dedicates this book to the memory of Matt Goodwin. Dr. Twohig would like to thank all the organizations that have supported this work, including Utah State University, the Trichotillomania Learning Center, the International OCD Foundation, the Association for Contextual Behavioral Sciences, the Association for Cognitive and Behavioral Therapies, the Huntsman Foundation, and many others. The development of this treatment would not have been possible without you.

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About the Authors

Douglas W. Woods received his PhD in clinical psychology from Western Michigan University in 1999. He is currently Professor of Psychology and Dean of the Graduate School at Marquette University. Dr. Woods is a recognized expert in the assessment and treatment of trichotillomania, Tourette syndrome, and other obsessive-​ compulsive (OCD) spectrum disorders. Dr. Woods is a Fellow of both the American Psychological Association and the Association for Behavioral and Cognitive Therapies. He also serves as a member of the TLC Foundation for Body-​ Focused Repetitive Behaviors’ Scientific Advisory Board and the Tourette Association of America’s Medical Advisory Board. He has published over 300 journal articles and book chapters on these and related topics, including nine books. Dr. Woods’ research has been funded by grants from the National Institutes of Health, the Trichotillomania Learning Center, and the Tourette Syndrome Association. Michael P. Twohig worked with Dr. Woods at the University of Wisconsin-​Milwaukee for 3 years before completing his PhD from the University of Nevada, Reno, in 2007. He is a licensed psychologist in Utah, where he has a small private practice in addition to being a Professor of Psychology at Utah State University. He co-​runs the ACT Research Group with Dr. Levin, and his research focuses on the treatment of OCD and OCD-​ related disorders such as trichotillomania and skin picking. He has authored over 200 scholarly works and regularly trains therapists in ACT and its use for OCD and related disorders. He is an author of ACT in Steps: A Transdiagnostic Manual for

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Learning Acceptance and Commitment Therapy (with Levin and Ong) and the Oxford University Press Handbook on Acceptance and Commitment Therapy (with Levin and Petersen). His recent work on the treatment of trichotillomania has been supported by generous donations from the Huntsman Foundation.

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Contributors

Eric B. Lee, PhD Southern Illinois University Carbondale, IL, USA

Julie M. Petersen, MS Utah State University Logan, UT, USA

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Introduction: Introductory Information for Therapists and Assessment With Eric B. Lee, PhD

Background Information and Purpose of This Program Trichotillomania (TTM) is a disorder of secrecy and shame. Many with the problem do not know it has a name, and many who know what they have cannot find knowledgeable providers. Research on the etiology, maintenance, and treatment of TTM has grown dramatically since this program was first published. Still, our understanding of this complicated disorder remains incomplete, and few effective therapeutic options exist. Behavior therapy still maintains the strongest empirical support (Farhat et al., 2020), having reliably outperformed medications in head-​to-​head, albeit small, efficacy trials. Unfortunately, the number of mental health providers familiar with TTM and its treatment remains limited. This therapist guide and client workbook were written as tools for therapists to become familiar with an effective treatment for TTM. Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-​ T) is a 10-​ session treatment package for adolescents and adults. The treatment blends the traditional behavior therapy elements of habit reversal training and trigger reduction strategies (HRT+​; Woods & Miltenberger, 1995) with the more contemporary behavioral elements of ACT (Hayes et al., 2011). The goal of this program is twofold: to teach clients to effectively manage their pulling and to actively increase the client’s functioning.

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Trichotillomania TTM involves the repetitive pulling of one’s hair to the point of noticeable hair loss and functional impairment. The Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-​5; American Psychiatric Association, 2013) criteria also require repeated attempts to stop the behavior, and the pulling cannot be explained by another psychiatric condition. TTM is much more common than previously believed. Prior to the publication of DSM-​5, the prevalence of TTM was estimated at 0.6% (Christenson et al., 1991b). However, research has repeatedly shown that when the rather arbitrary “tension and reduction” criteria (which was included in DSM-​IV) are excluded, prevalence rates increase substantially (Christenson et al., 1991a; Ghisi et al., 2013). In DSM-​5, the “tension and reduction” criteria were removed. Since then, one large population prevalence study showed a current prevalence rate of 1.7% (Grant et al., 2020). In clinical settings, TTM is more common in women, with estimates of female-​to-​male ratios in the range of 3 to 9:1 (Christenson et al., 1994). Nevertheless, some recent population-​based studies have suggested the gender distributions may be more balanced (e.g., Ghisi et al., 2013; Grant et al., 2020). TTM also follows a chronic waxing and waning course (Stein et al., 1999), and the average age of onset is believed to be 10 to 13 years (Grant & Chamberlain, 2016).

Impairment Associated with TTM People with TTM experience a variety of physical and other impairments. Interestingly, a later age of onset is associated with greater impairment, as is a shorter duration of illness (Grant et al., 2016). Along with the requisite hair loss, TTM can produce a variety of physical difficulties. For example, clients report scalp irritation, follicle damage, atypical regrowth of hair, dental damage (e.g., gum disease and enamel erosion from hair mouthing), finger calluses, muscle fatigue, and carpal tunnel syndrome (Keuthen et al., 2001). Even more concerning is the possible development of trichobezoars (conglomerates of hair and food that form in the gastrointestinal tract). Although mouthing of pulled

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hair is common and occasional ingestion occurs (Snorrason et al., 2021), if hair is routinely ingested, trichobezoars can form and lead to weight loss, internal bleeding, ulcers, perforations in the gastrointestinal tract, pain, nausea, and, in rare cases, death (Snorrason et al., 2021). In many cases, surgical removal of the trichobezoar may be required (Gorter et al., 2010). Individuals with TTM are also likely to experience a host of social, academic, occupational, and financial difficulties. They frequently avoid leisure activities, going to the hairdresser, and going outside on windy days (Bottesi et al., 2016b; Woods et al., 2006a). Along with greater severity typically comes greater impairment (Grant et al., 2016). Individuals with visible hair loss may avoid intimate and social relationships or certain occupations in which hair loss is noticeable, and they may contemplate suicide (Seedat & Stein, 1998; Woods et al., 2006a). Individuals with TTM also report that pulling has caused difficulties in studying (Bottesi et al., 2016; Woods et al., 2006a). Limited data exist on the occupational impact of TTM, but one study found that 55% of persons with TTM reported occupational impairment as a direct result of the pulling (Keuthen et al., 2002). Finally, individuals with TTM often are affected financially by trying to mask the effects of the disorder through purchases of wigs, coverings, and makeup to hide damaged areas. Not only does TTM lead to increased psychosocial impairment, but psychiatric symptoms can also be worse in those with TTM. In a large series of studies conducted on the impact of TTM, 70% of respondents with TTM felt that TTM had led to the development of additional psychiatric disorders (Woods et al., 2006a). As a whole, the sample experienced clinically elevated symptoms of depression, anxiety, and stress, which were similar in magnitude to those found in samples of persons with obsessive-​compulsive disorder (OCD; Antony et al., 1998). Indeed, TTM appears to be associated with high psychiatric comorbidity (Houghton et al., 2016a), as 35% to 55% of individuals with TTM have a lifetime history of major depression, 50% to 57% have a history of anxiety disorders, 22% to 35% have a history of substance use disorders, and approximately 20% have experienced eating disorders (Houghton et al., 2016a). In sum, up to roughly 80% of individuals with TTM currently meet or have met criteria for a comorbid diagnosis (Houghton et al., 2016a).

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Fewer data exist on the impairment and psychiatric comorbidity associated with TTM in children and adolescents, but those that do exist yield similar results. For example, Franklin et al. (2008) surveyed 133 children and adolescents with TTM and found slightly elevated symptoms of anxiety and depression, which were both correlated with TTM severity. The sample also reported moderate levels of impairment across multiple domains of functioning. Interestingly, some evidence suggests that participants in online samples experience greater impairment from pulling than participants from face-​ to-​ face samples (Bottesi et al., 2016b), supporting the notion that TTM is often a disorder of secrecy.

Diagnostic Criteria for TTM Box I.1 summarizes the DSM-​5 criteria for trichotillomania.

Behavioral Model of TTM

Mansueto et al. (1997) offered the first comprehensive model for TTM, which encouraged clinicians to understand the multiple levels and sources of influence that could maintain pulling. Mansueto’s model has had a profound impact on how TTM is understood and treated. Prior to this model, treatment focused primarily on HRT, but treatment now

Box I.1  DSM-​5 Criteria for TTM The following is a general description of the criteria necessary to meet a diagnosis of trichotillomania: A. Repeated pulling of hair from the body that leads to hair loss or thinning B. Patient has tried unsuccessfully to stop or reduce pulling C. The pulling leads to meaningful disruption in the patients physical and/​or psychosocial functioning D. The pulling is not the result of another physical or psychiatric condition E. The hair pulling is not better explained by the symptoms of another mental disorder. Source: Criteria based on The Diagnostic and Statistical Manual of Mental Disorders (5th edition), American Psychiatric Association (2013).

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regularly incorporates interventions to prevent pulling episodes from occurring and highlights the importance of focusing on interventions to deal with the private experiences that often give rise to pulling (e.g., urges, sensory experiences, emotions, cravings, cognitions). In the following sections, we broadly review the types of variables Mansueto et al. implicated in the original comprehensive model of TTM. In addition, we discuss new findings that have helped to shape our own model (Wetterneck & Woods, 2007). The most striking difference between the models involves the functional role of inner experiences (e.g., cognitions, urges, cravings, emotions) in the maintenance of pulling. We agree with Mansueto et al. that these variables influence pulling; however, there is some discrepancy in the target of intervention. Traditional cognitive-​behavioral therapy (CBT) methods, which stem from Mansueto’s model, have focused primarily on reducing or otherwise altering the inner experiences in the service of pulling reduction. Such therapy focuses on more accurate thinking, learning to relax, replacing sensory experiences, or determining how to reduce the urge. Recent research suggests, however, that it is not simply the urges, cravings, cognitions, and emotions that may be responsible for some episodes of pulling, but rather the larger psychological context that the client brings to the table. If the client has a general tendency to avoid, reduce, or escape from unwanted inner experiences (a pattern called “experiential avoidance”), and sees them as meaningful and powerful (cognitive fusion), only then do the inner experiences exert influence over pulling. As a result, the current treatment de-​emphasizes attempts to modify or eliminate inner experiences and focuses instead on seeing inner experiences for what they are and learning to function with such phenomena. The various factors that have been implicated in the maintenance of pulling are described in the sections that follow. These factors include antecedent triggers and reinforcing consequences, which can be environmental, sensory, cognitive, emotional, and cultural.

Environmental Factors Associated with Pulling A number of environmental factors have been associated with increased TTM symptoms, including different settings or activities. For example, pulling commonly occurs in one’s bedroom and/​or bathroom and is

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likely to increase with sedentary activities such as driving, reading, and watching television (Duke et al., 2010). Similarly, various bodily positions can increase the likelihood of pulling. For example, sitting on a couch with one’s hand near a high-​risk pulling site can occasion the behavior. Pulling may also be more likely to occur during certain times of day, such as the evening. Various social consequences can serve to maintain pulling in some individuals. For example, reactions to pulling from caregivers, teachers, and peers could inadvertently reinforce the behavior.

Sensory Factors Associated with Pulling Specific physical, visual, and tactile stimuli also frequently evoke pulling. For example, hair pullers often seek out target hairs that possess specific physical qualities such as a certain color, shape, or texture. Stein et al. (1999) noted that coarse, thick, wiry, or stubbly hairs are often pulled. Various sensory changes following pulling contribute to TTM by reinforcing the pulling. For example, specific tangible features of the hair may actually reinforce pulling or pre-​pulling behaviors (e.g., the tactile stimulation achieved from stroking hair or otherwise twisting hair; Mansueto et al., 1997; Rapp et al., 2000). The pulled hair may be rubbed against a person’s body, often the face or between fingers, or certain types of hairs (e.g., coarse hair or those with plump roots) may be more appealing to the puller (Bottesi et al., 2016b). People with TTM often spend more time manipulating hair than actually pulling hair (Miltenberger et al., 1998). Given general descriptions of TTM and how important visual and tactile stimuli seem to be in the disorder, it is not surprising that researchers have begun to investigate sensory processing problems in persons with the condition. The limited research suggests that individuals with TTM process sensory information differently than non-​affected controls. For example, a study by Houghton at al. (2018) found that individuals with body-​focused repetitive behaviors (BFRBs, including TTM) are generally more sensitive to sensory input and experience greater sensory avoidance than non-​affected persons. Similarly, Houghton et al. (2019) found that adults with BFRBs (including TTM) reported greater difficulties keeping unwanted sensory experiences out of their minds (i.e., decreased sensory 6

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gating) and had greater tactile sensitivity than non-​affected controls. Finally, a study by Falkenstein et al. (2018) found that individuals with TTM reported greater responsivity to auditory and tactile stimuli relative to a non-​affected comparison sample. Combined, these data suggest that individuals with TTM may be more sensitive to sensory stimuli, while also showing a greater tendency to want to escape from these sensory stimuli. Given that pulling is an efficient way to eliminate some aversive sensory experiences, it is not surprising that those who are bombarded by and seek to avoid sensory experiences may be more likely to pull. Furthermore, if an individual is hypersensitive to tactile stimuli but does not have a strong tendency to avoid such stimuli, then tactile stimuli caused by pulling could be a particularly powerful reinforcer.

Cognitive Factors Associated with Pulling Cognitive factors are a common antecedent for pulling. Wetterneck et al. (2020) found that 85% of persons with TTM reported thoughts, ideas, or images immediately preceding pulling episodes, and 70% endorsed general “mental anxiety” prior to pulling. Specific thoughts may also cause pulling. For example, seeing a coarse, gray, or “out-​of-​ place” hair in the mirror may evoke thoughts that lead to the removal of the hair (e.g., “My eyebrows should be symmetrical” or “Gray hairs are bad, and I need to remove them”). In addition, those with more dysfunctional beliefs about their appearance, greater thoughts of shame, and fears about being evaluated negatively experience more severe TTM (Norberg et al., 2007). Growing research also has suggested that persons with TTM may have impairments in targeted domains of cognitive functioning. In a recent review of neuropsychological research, Slikboer et al. (2018) suggested that persons with TTM may have deficits in divided attention, visual memory, and working memory. In another interesting study, Lee et al. (2012) found that persons with TTM were more likely to engage in attentional avoidance from images related to hair or to a general threat. Combined, these data suggest that pulling may also (a) function to distract the person from unwanted cognitions, (b) allow the person to focus their attention, and/​or (c) reduce anxiety or distress resulting from particular cognitions. 7

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Emotional Factors Associated with Pulling Emotional experiences impact pulling. Research has focused primarily on how states such as anxiety, tension, and boredom evoke pulling, but other emotional states such as loneliness, fatigue, guilt, anger, indecision, frustration, and excitement have also been implicated (Mansueto et al., 1997). Prior to pulling, those with TTM report bodily sensations (e.g., general tension, sensations localized to specific areas) or general discomfort (e.g., vague urges, inner pressure, or feeling not “just right”; Wetterneck et al., 2005). Recognizing that emotions often have physiological, cognitive, and behavioral components, Alexander at al. (2017) found that the cognitive but not somatic dimensions of anxiety predicted pulling severity in a group of persons with TTM. Not only can emotions trigger pulling, but growing evidence suggests emotion-​regulation difficulties may be related to TTM. Arabatzoudis et al. (2017) compared 20 individuals with TTM to 43 control participants. Results showed that those with TTM reported greater difficulties regulating their emotions and poorer tolerance relative to the control group. Another study by Shusterman et al. (2009) showed a significant correlation between difficulties in affect regulation and hair-​ pulling severity. They went on to show that certain types of emotions are generally correlated to pulling, including boredom, anxiety, and tension. Bottesi et al. (2016a) explored the possible impact of pulling on emotions by investigating changes in emotions from before to during a pulling episode. Results showed that participant-​reported pleasure, relief, and indifference increased, but boredom decreased. Combined, these data suggest that individuals with TTM (a) are likely to have difficulties regulating emotional states, (b) are more likely to experience emotions more often and more strongly, and (c) often pull to alter particular emotional states.

Cultural Factors Associated with TTM Research on cultural factors related to TTM is scarce but points to differences in minoritized racial groups that could support the use of distinct approaches to treatment and that should be considered by those striving to be culturally sensitive and effective treatment providers. 8

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Prevalence rates of TTM appear to be similar across racial groups (Grant et al., 2020; Gutierrez et al., 2021), although there is some evidence that rates are somewhat higher from children in minoritized groups compared to White children (Neal-​Barnett et al., 2010). It appears that those from minoritized racial groups, on average, differ from White individuals in how they experience TTM (Neal-​Barnett et al., 2010). Some of these are differences in form, as minoritized individuals appear less likely to pull from their eyelashes and eyebrows. Other differences relate to functional differences in behavior and experience, such as minoritized individuals reporting less tension before pulling, more interference with home management due to pulling, and less overall stress. Neal-​Barnett and Stadulis (2006) suggest that lower stress in African Americans who pull their hair may be a result of the hair pulling lowering one’s private regard (i.e., the extent to which one feels positively about being a member of the African American community). This in turn leads to a resignation that they are a “chronic hair puller” who then exhibits a calm, detached stance toward their pulling behavior. Moreover, it appears that minoritized individuals are on average less likely to utilize treatment compared to White individuals (Neal-​Barnett et al., 2010). Instead, it seems that many African Americans choose to consult hair care professionals, with whom they have preestablished close relationships. Interviews with 39 hair care professionals who served predominately African American customers found that 74% reported having regular customers with significant signs of hair-​pulling behavior (Neal-​Barnett et al., 2000). Another small study found that participants in minoritized racial groups responded more poorly to a web-​based, self-​help portion of a treatment package compared to White participants (Falkenstein et al., 2015). For many Black individuals, especially women, hair is a defining and emotionally fraught issue. The physical properties of most African American hair, such as texture, can differ significantly from White hair (Neal-​Barnett et al., 2000). Moreover, perceived hair quality can have a meaningful influence on Black women’s perception of their attractiveness, self-​esteem, and self-​worth. Black women’s hair care routines, alterations, and habits are often culturally bound and unique compared to other cultures. Neal-​Barnett et al. (2011) explain the need for culturally informed care, stating that “the existence of and value placed

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on these messages suggests that to fully understand TTM in African Americans, culture must be investigated” (p. 211). Even when TTM symptoms are similar in form, culture may influence other aspects of the problem, such as coping, help-​seeking, and impact.

Role of Psychological Inflexibility Interestingly, there is growing evidence that the relationship between specific inner experiences and TTM severity may be moderated by an individual’s history of escaping or avoiding unpleasant emotions or cognitions they view as particularly powerful. This variable, called psychological inflexibility, may be particularly important in the analysis of TTM. An early study by Begotka et al. (2004) found a significant relationship between pulling severity (as measured by the Massachusetts General Hospital Hairpulling Scale [MGH-​ HS]; Keuthen et al., 1995) and psychological inflexibility (as measured by the Acceptance and Action Questionnaire [AAQ]; Hayes et al., 2004). With respect to the relationship between various emotional states and pulling severity, it was found that worry and physiological arousal prior to pulling were significantly correlated with higher TTM severity, but this relationship was moderated by psychological inflexibility (Wetterneck & Woods, 2005). Likewise, in another study, Alexander et al. (2017) showed that psychological inflexibility mediated the relationship between the cognitive aspects of anxiety and pulling severity. Such results suggest that by decreasing psychological inflexibility, one could decrease the impact of anxiety-​related cognitions on pulling severity. A similar finding was demonstrated by Houghton et al. (2014), who showed that psychological inflexibility as assessed by the AAQ-​TTM fully mediated the relationships between depressive symptoms and hair-​pulling severity and between anxiety symptoms and pulling severity. In sum, these data suggest that the more someone buys into and attempts to avoid or control unpleasant inner experiences related to TTM, the more likely they are to pull in reaction to an urge, cognition, or negative emotion. Overall, research has shown that sensory experiences, cognitions, and emotions, including urges to pull, play a meaningful role in the development and maintenance of TTM. These findings also suggest that it

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is not the mere presence of these inner experiences that predicts greater TTM severity. Rather, the process of fighting against, controlling, and otherwise attempting to avoid or escape one’s thoughts about or urges to pull might be a key variable to address in the treatment of TTM. Thus, from our perspective, treatment should focus on decreasing the influence these inner experiences have on pulling by decreasing the client’s efforts to control them. For this reason, we have incorporated an acceptance-​based procedure, ACT, as it focuses on teaching people how to reduce the influence of, and their own fight against, their inner experiences.

Evidence for Different Processes Underlying Pulling Mounting evidence suggests at least two unique processes underlying pulling in TTM. Focused pulling is preceded by an inner experience such as an urge, bodily sensation (e.g., itching or burning), emotion (e.g., anxiety), or cognition (e.g., “I can’t stand this any longer”). Focused pulling is believed to be an intentional behavior designed to temporarily reduce or escape from these experiences or acquire a short-​term pleasurable sensation (Grant et al., 2007). In contrast, automatic pulling seems to occur outside of one’s awareness, often during sedentary activities (e.g., watching television, reading, or driving) and without any identifiable inner antecedent. It is commonly believed that many individuals with TTM experience both processes, and it can often be difficult to tell, during any one episode of pulling, which process is active. For this reason, AEBT-​T includes different interventions for these two processes, and it is important that both interventions be used in the prescribed manner. Empirical research on the validity of the focused and automatic distinction is growing, though the construct is not universally accepted. For example, one study found that in 47 clients with TTM, 34% characterized their pulling as primarily “focused,” 47% as primarily “automatic,” and 19% as equally focused and automatic (du Toit et al., 2001). In another study, those with primarily focused pulling, primarily automatic pulling, and mixed focused and automatic pulling were compared on the Depression Anxiety Stress Scale (DASS)-​21 subscales after controlling for TTM severity (Flessner et al., 2008b). Results 11

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suggested that those individuals with primarily automatic pulling experienced less depressive, anxiety, and stress symptoms than those with primarily focused or mixed patterns. Likewise, those with mixed pulling experienced more depressive, anxious, and stress symptoms than those with either primarily focused or automatic pulling. Relatedly, results from a study by Arabatzoudis et al. (2017) showed that focused pulling severity was correlated with various emotion regulation difficulties, such as difficulties in engaging in goal-​directed behavior when distressed and the tendency to respond impulsively to unpleasant emotions. Research also suggests that the different pulling processes are differentially related to psychological inflexibility. Focused but not automatic pulling scores on the Milwaukee Inventory for Subtypes of Trichotillomania—​Adult Version (MIST-​A; Flessner et al., 2008a) were significantly positively correlated with psychological inflexibility (Begotka et al., 2003).

Development of This Treatment Program and Evidence Base The AEBT-​T program was originally developed and tested for treating adults with TTM. Subsequent research has offered compelling evidence that the treatment is effective down to the age of 12 (Fine et al., 2012; Lee et al., 2020; Twohig et al., 2021; Woods et al., 2022), although Lee et al. suggested treatment may be more robust in adults. The program was intended for therapists who are familiar with behavior therapy and who have familiarized themselves with acceptance-​or mindfulness-​ based treatments. In addition, as this program was developed, it was expected that therapists would possess and integrate into the treatment an exceptional set of broad therapeutic skills (e.g., empathy, summarization, reflective listening). The program was developed based on the aforementioned model of TTM. In this model, TTM is viewed as involving two core pulling processes: automatic and focused pulling. Given these two processes, the treatment used HRT/​trigger reduction procedures to treat the habitual automatic pulling and ACT to treat focused pulling via reduction of psychological inflexibility. The original program was evaluated and revised through an empirical process. In the initial feasibility trial of AEBT-​T (Twohig & Woods,

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2004), a seven-​session treatment manual was tested in six adults with TTM using a multiple baseline across subject design. Treatment was delivered in weekly individual sessions. Self-​reports of pulling showed that AEBT-​T resulted in decreases to zero levels of pulling for four of the six subjects, and the results were maintained for three of the four subjects at a 3-​ month follow-​ up. Moderate decreases were seen in pulling for the remaining two subjects. MGH-​HS scores collected at pretreatment, posttreatment, and follow-​up showed a 63% reduction at posttreatment, with gains maintained at follow-​up. Independent photograph ratings confirmed the self-​report findings, and all subjects evaluated the treatment positively. Based on the feasibility trial, the manual was revised to increase the number of sessions from seven to 10 and incorporate relapse prevention techniques. This revised approach was then tested in a small randomized clinical trial funded by the TLC Foundation for Body-​Focused Repetitive Behaviors (www.bfrb.org), a national patient advocacy organization for individuals with TTM and related BFRBs. Twenty-​eight participants were randomly assigned to one of the two conditions (14 AEBT-​T and 14 waitlist [WL] control). A masked independent evaluator (IE) conducted assessments before and after treatment. At the end of the posttreatment assessment, the WL participants were offered AEBT-​T and reassessed at the end of treatment. All individuals in the initial AEBT-​T condition were reassessed at a 3-​month follow-​up. In addition to assessing pulling severity with the MGH-​HS and IE ratings (National Institute of Mental Health Trichotillomania Impairment Scale [NIMH-​ TIS] rating), depression and anxiety measures were taken, as was a measure of psychological inflexibility. Pulling severity across the two primary outcome measures (i.e., pulling severity and related impairment) decreased for the AEBT-​T group but not for the WL group. After the WL group received AEBT-​T, they also showed significant decreases in all indicators of pulling severity. Overall, 66% of AEBT-​T recipients were deemed “treatment responders,” and significant differences were maintained at the 3-​month follow-​up on the MGH-​HS. In addition to the gains seen in hair-​pulling symptoms, depression and anxiety scores also decreased for the AEBT-​T group but not for the WL group (Woods et al., 2006c). Additional analyses of potential mechanisms of change indicated that pre–​post decreases in a psychological inflexibility measure (as measured

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14

by the AAQ) were moderately and significantly correlated with pre–​ post decreases in pulling severity (r =​.59). Subject compliance ratings completed by both clinician and participant were also positively and significantly correlated with symptom reduction at posttreatment (r =​ .57–​.67). Since this first randomized controlled trial, a number of other studies have been conducted, each showing outcomes similar to the original studies. An open trial of 53 outpatients tested the effects of AEBT-​T delivered in group format (Haaland et al., 2017). Results showed a significant decrease in TTM severity as measured by both self-​report and assessment of an IE. Furthermore, 88% of the participants were considered clinical responders. These gains were maintained at the 1-​ year follow-​up. In another study of AEBT-​T delivered in group format, Asplund et al. (2021) found that treatment produced significant posttreatment reductions in pulling and picking in a mixed sample of 40 adults with TTM and skin-​picking disorder. Interestingly, pulling relapsed at the 12-​month follow-​up and pulling gains were lost, whereas the picking symptoms remained improved. Crosby et al. (2012) also showed significant improvement in all five patients described in a case series evaluating AEBT-​T, but only two of the five maintained gains at the 3-​month follow-​up. In a set of studies by Dr. Twohig’s lab, the AEBT-​T protocol was delivered over teletherapy (Zoom) with adults (N =​22; Lee et al., 2018) and adolescents (N =​28; Twohig et al., 2021). Both studies randomized participants into AEBT-​ T or WL control conditions. Both studies found greater reductions in pulling severity for AEBT-​T compared to the control condition. These trials demonstrate this program can be successfully delivered over teletherapy, possibly helping ease the concerns around limited therapist access. This same group tested a protocol of ACT alone (i.e., without HRT or trigger reduction procedures) on treatment-​ seeking adults and adolescents with TTM (Lee et al., 2020). Participants (N =​39) were randomized to 10 sessions of ACT focused on increasing psychological flexibility around urges to pull and increasing behavioral commitments to not pull, or to a WL condition. The sample included 14 adolescents and 25 adults. Results showed significant pulling reduction and a 60%

14

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clinical response rate for those receiving ACT. Responses were stronger for adults than adolescents. Consistent with the model, treatment resulted in a 25% decrease in psychological inflexibility but little change in pulling-​related inner experiences. In the largest randomized controlled trial on TTM to date, Woods et al. (2022) compared AEBT-​T to a psychoeducation and supportive therapy control condition in 85 adults with TTM. Results showed that AEBT-​T was more effective than the control treatment in reducing pulling severity as assessed by a masked IE, thus suggesting that AEBT-​T is not due entirely to the nonspecific factors associated with psychotherapy. Furthermore, results showed that 64% of the AEBT-​T recipients were clinical responders to treatment. Overall, results of studies evaluating AEBT-​T suggest a strong treatment that is effective for reducing TTM severity and produces meaningful clinical response. Questions remain about the durability of the results, however. More importantly, growing research has shown that symptom reduction may be linked to the process of greater psychological flexibility, the very processes targeted in ACT.

Role of Medications The most common intervention for TTM remains pharmacotherapy (Woods et al., 2006b) despite the fact that evidence supporting this strategy is quite limited. Typically, selective serotonin reuptake inhibitors (SSRIs) are the treatment of choice (Woods et al., 2006b). One study (Swedo et al., 1989) has demonstrated the superiority of medications (i.e., clomipramine) over placebo, and the two randomized controlled trials comparing behavior therapy to SSRIs found that behavior therapy outperformed the medications (Ninan et al., 2000; van Minnen et al., 2003). N-​acetylcysteine (Grant et al., 2009) and olanzapine (Van Ameringan et al., 2010) have been found to be effective in reducing pulling in small randomized placebo-​controlled trials. Despite limited support for medications in reducing TTM symptoms, they may be helpful in managing the disorders developing secondary to TTM, such as depression or social phobia, or for those disorders that co-​occur with TTM and can exacerbate TTM symptoms (e.g., anxiety).

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Overview of AEBT-​T AEBT-​T is a combination of HRT, trigger reduction strategies, and ACT. Selection of these treatment elements was guided by the behavioral model of TTM described earlier. HRT/​trigger reduction and ACT are behavior therapies based on the principles of operant learning theory, which describes how environmental antecedents and consequences can interact with a particular biological makeup to cause and maintain certain patterns of responding. ACT is further informed by relational frame theory (Hayes et al., 2001), a behavior analytic account of language and cognition that attempts to explain how inner experiences influence traditional behavioral processes. The purpose of AEBT-​T is to educate the client about TTM and teach them to: ( a) be aware of their pulling and its antecedents, (b) use self-​management strategies to prevent or stop the pulling, (c) stop fighting against inner experiences that lead to pulling by learning skills such as defusion and acceptance, and (d) work consistently toward increasing quality of life. Elements of HRT and trigger reduction are incorporated, as they are believed to be effective in treating automatic pulling. HRT/​trigger reduction procedures focus on bringing the pulling into awareness and providing and reinforcing the use of strategies to prevent the pulling or to make it more difficult. ACT is utilized primarily to target the processes underlying focused pulling. ACT procedures focus on teaching the client skills to step out of the struggle with internal experiences that lead to pulling. The goal of ACT is not to try and alter these inner experiences, nor do ACT therapists suggest or even imply that an accepting stance toward these stimuli will ultimately result in their cessation. Rather, the therapist creates a therapeutic context through the use of metaphors and experiential exercises that supports viewing urges, thoughts, or feelings as stimuli to be observed rather than acted on. Clients learn that when such stimuli are present, they are present. When they are absent, they are absent. When they are weak, they are weak, and when they are strong, they are strong. The therapist works to offer the client a perspective that

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allows them to see that they have a choice to either (a) experience the private events and refrain from pulling while engaging in more meaningful activities or (b) fight with the private events, pull to control them, and, as a result, be drawn further from areas of life that are really important to them. Following is a brief overview of treatment sessions: ■ Session 1. The therapist provides an overview of AEBT-​ T, psychoeducation about TTM, a review of factors likely to exacerbate pulling, an introduction to the self-​ monitoring homework assignments, and a discussion of therapeutic expectations. Session 2. This session includes the implementation of trigger reduc■ tion strategies and HRT. Session 3. The therapist and client begin to identify what is impor■ tant to the client and ways in which reducing pulling can increase quality of life. Session 4. Further discussion is held about perceived barriers to ■ pursuing a better quality of life. These barriers stem from attempts to control unwanted inner experiences. After identifying strategies the client uses to control urges to pull as well as emotions, thoughts, and feelings surrounding the pulling, the therapist and client discuss the effectiveness of current strategies. The goal of the session is to demonstrate the ultimate ineffectiveness of and problematic results stemming from attempts to control urges, emotions, thoughts, and feelings. We also start behavioral commitments to reduce pulling in this session. Behavioral commitments will continue to be stressed throughout therapy. Session 5. This session is a continuation of the topics discussed in ■ Session 4. Additional time is spent on how someone can fall into the trap of trying to control urges and other inner experiences. Through experiential exercises and the use of metaphors, the client can experience the difficulty involved in suppressing or controlling inner experiences. Alternative ways (other than pulling) of responding to inner experiences are discussed. After relating this difficulty to the client’s attempts at controlling inner experience through pulling, they are asked to consider the possibility of experiencing willingness to accept pulling-​related inner experiences as a potentially alternative response. Behavioral commitments to reduce pulling are continued.

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■ Sessions 6 and 7. The client begins to learn that one can experience the pulling-​related inner experiences as observable responses rather than as literal objects or truth. This process is called “cognitive defusion.” Behavioral commitments to reduce pulling are also continued. Session 8. The client has an opportunity to practice the material ■ presented in previous sessions. The client is also encouraged to embrace the urge by being exposed to various cues that are likely to evoke the urge to pull. Behavioral commitments to reduce pulling are continued. Session 9. The client is again given the opportunity to practice the ■ techniques learned in therapy, and material covered in therapy to date is reviewed. Behavioral commitments to reduce pulling are continued. Session 10. The processes needed for each client are determined. This ■ assessment may involve a review of values, acceptance, and defusion, as well as of the HRT and trigger reduction procedures. This final session also involves the implementation of relapse prevention procedures, including discussions on lapse versus relapse, vigilance with HRT and trigger reduction procedures, and the return of fusion and cognitive or emotional control. We also provide session-​specific modifications that can be made ■ to better address the needs of adolescents. As some of these modifications can work across sessions, we have provided them all together in Chapter 10. Appendix A. This appendix includes the standardized assessments ■ that you may give your client at the beginning of treatment and use to track progress. It includes the MIST-​A, Milwaukee Inventory for Styles of Trichotillomania—​Child Version (MIST-​C), AAQ-​TTM, and Pulling Triggers Assessment Form (PTAF). These items can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Appendix B. This appendix contains the client graphs, forms, and ■ worksheets so that the therapist can refer to them in one place. All of these items also appear in the client workbook and can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Appendix C. Finally, we offer a set of caregiver handouts. These are ■ useful for sessions where most of the work is completed with the 18

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adolescent and you want to make sure the caregivers are aware of what you are working on and how they might assist at home. It is important to note that while AEBT-​T was originally designed as a 10-​session treatment, you should use your data-​guided clinical judgment to determine how rapidly to progress through therapy and when termination is appropriate. Also, you should consider the possibility that periodic booster sessions may be required for maintenance of results.

Pitfalls to Avoid When Using AEBT-​T During our development and initial presentations of this work, we have run into common points of confusion. In the discussion that follows, we list each of these points and clarify how they are handled within the therapist guide and client workbook.

Acceptance Does Not Mean Teaching the Client to Accept Hair Pulling Rather than viewing acceptance as the equivalent of a general unconditional acceptance for everything a person does, our definition of acceptance is specific. Acceptance refers to the acceptance of those uncontrollable internal experiences that lead to pulling, not acceptance of the pulling itself or other life events that might be changeable.

Does Blending the Two Interventions Create Confusion? On the one hand, individuals can view HRT and trigger reduction as control-​focused interventions, and they are correct. On the other, ACT is clearly not a control-​focused strategy. We acknowledge the surface contradiction here, but there are clear distinctions that can eliminate confusion and provide specific benefits of blending the two approaches. The target of each intervention is different: HRT and trigger reduction procedures focus on eliminating and making more effortful the overt behavior. In comparison, ACT focuses on covert or inner experiences and 19

20

does encourage changing overt behavior if such behavior interferes with one’s values, which pulling often does. There are various benefits to using both procedures. First, when implementing HRT and trigger reduction procedures, clients may describe difficulties with implementation. They may say things such as “I tried, but it was too hard; the tension got too great” or “I had some really good days, but then I got in a fight with my husband, and I went into a pulling episode to relax.” Such statements provide therapeutic material on which ACT can be based. Second, in the ACT component, the client is challenged to do “behavioral commitment exercises,” in which they seek out high-​risk pulling situations and practice being willing to experience the private events that show up for them. In this case, the client can be encouraged to use HRT and trigger reduction procedures as a tool to help control pulling during these exercises, thereby allowing the unpleasant inner experiences to be present.

Trigger Reduction Strategies Should Focus Only on Making the Pulling Less Likely to Occur Do not design trigger reduction interventions to specifically alleviate or prevent the unpleasant urges, emotions, or cognitions that precede pulling. Trigger reduction strategies should only be presented as a way to reduce the likelihood of pulling. Describing trigger reduction strategies as a way to alleviate or prevent inner experiences runs counter to the ACT philosophy and will likely undermine treatment efforts. In addition, you should be flexible in the implementation of trigger reduction strategies. At certain points in the treatment, it may be desirable to stop trigger reduction strategies if they are found to be reducing the urge to pull.

What Is the Role of Values? Values are defined as engaging in actions consistent with broad areas of life that are important to the client. These behaviors are done without regard for their effects on inner experiences. We use the term quality of life or areas of importance interchangeably. Values are also different from

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goals in that a value can never be reached—​values function to guide behavior without end. Clients and therapists can become confused when discussing how pulling interferes with the client’s work on values. At the beginning of values work, the client will often say things like “I value having eyelashes” or “I value looking good.” These are all worthy things to work toward, but the good therapist will work with the client to consider what pulling is taking the client away from. For example, if the client values being a good mother or employer yet engages in pulling for 3 hours per day, is that time spent being a good mother or a good CEO? Maybe letting go of controlling the urge would allow her to behave in a way that is consistent with her value of being a good mother or CEO.

Use of the Client Workbook As with any behavior therapy, successful completion of between-​session work and full participation in treatment are vital. To aid in the assignment and completion of between-​session work and to encourage full participation, the client workbook has been created. The workbook contains all necessary materials to help the client successfully complete treatment. Specific forms include all necessary self-​monitoring forms, checklists about antecedent and consequent cues to pulling, psychoeducational materials that can be read at the client’s leisure, and various forms used to facilitate therapeutic exercises in and outside the session.

Assessment Assessment of TTM involves initial assessment and ongoing monitoring of therapeutic progress. Here we focus on the initial assessment, whereas assessment of progress throughout treatment is discussed in the description of individual sessions. This chapter does not present a comprehensive psychological assessment strategy, but rather provides a description of various assessment domains that therapists who treat persons with TTM should consider. When possible, references to specific instruments are provided.

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Pretreatment Assessment Following the diagnosis of TTM, a pretreatment assessment should be conducted. This pretreatment assessment should focus on five areas: history of the disorder and prior attempts at treatment, description of current symptoms and their severity, functional assessment of pulling, comorbid conditions and differential diagnoses, and global life functioning.

History of Pulling and Prior Attempts at Treatment Determine when and under what circumstances pulling started for your client and inquire about the client’s previous attempts at treatment. Such information is useful in that it helps you understand how the client views TTM in the context of their history and provides you with an understanding of how the client may view the therapeutic process (e.g., with mistrust, hope, doubt, lack of enthusiasm). TTM usually starts in early adolescence and is generally consistent across cultures (Grant & Chamberlain, 2016). When asking clients about the earliest pulling episodes, one of two patterns will likely emerge. Clients typically state that pulling developed at either a very young age (e.g., 2 or 3 years old) and simply remained, or in early adolescence (e.g., 11 to 13 years old), with the pulling chronically waxing and waning since that time. Sometimes the first pulling episode can be vividly recalled, and sometimes the onset is vague. Occasionally, clients will relate pulling onset to a particularly stressful life situation (e.g., abuse, death of a parent). Although such life stressors may indeed be a trigger for some individuals, research does not support the occurrence of traumatic or other stressful life events as the sole, necessary, or unique trigger for TTM (Houghton et al., 2016b). It can also be useful to discuss early reactions to pulling. How did the child’s caregivers respond? How did their peers react? Such information may be useful in helping you understand how the client came to relate to their symptoms. Because the current treatment program focuses on successful management of the current environment rather than correcting a past event, the

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client’s historical account of pulling onset does not substantially influence implementation of AEBT-​T. Nevertheless, historical information can be useful in forming a common basis of communication about the client’s symptoms and useful material for later exercises. It can also be helpful in appreciating the self-​generated rules and cognitions that play into their pulling (e.g., “No matter what I try, nothing helps me stop pulling”). You should also be aware of the client’s treatment history. Individuals diagnosed with TTM will likely have a long history with the disorder. Adults with TTM are likely to have attempted and failed multiple treatments, including medications, diets, and therapies. This chronicity is in part due to TTM being a difficult disorder to treat and in part to most mental health professionals not being sufficiently trained in its treatment (Marcks et al., 2006). While awareness of TTM is increasing, we still meet many clients who have struggled for many years without knowing about TTM and how it can be managed. Therefore, it is likely that clients will be hopeful, but skeptical, about therapists’ abilities to serve as an agent of change. You should be open and appreciative of the client’s likely frustration with prior attempts at treatment.

Description of Current Symptoms and Severity It is important to develop an understanding of the client’s pulling and to assess its severity. Table I.1 lists areas where pulling can occur and includes the prevalence of pulling from each area of the body, as found in the general TTM population. As can be seen, pulling is most likely to occur on the scalp, eyelashes, and eyebrows. These are also the most common sites in children ages 10 to 17 (Franklin et al., 2008). Although common, pubic pulling is not readily disclosed, and the astute therapist should ask about its occurrence, while recognizing the sensitive nature of the question. Damage from pulling ranges from complete baldness, to well-​ distributed thinning of hair, to no noticeable damage. Individuals who have TTM can be very good at hiding their damage, so you may need to request descriptions or be shown the damage; do not assume you

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Table I.1  Pulling Site Checklist and Percentage of Those with TTM Who Endorse Site as a Pulling Site Site

Yes

No

Normative (%)

Scalp

□

□

73

Eyebrows

□

□

56

Eyelashes

□

□

52

Pubic region

□

□

51

Legs

□

□

22

Arms

□

□

12

Armpits

□

□

12

Trunk

□

□

7

Moustache

□

□

5

Beard

□

□

4

Cheek, chin

□

□

2

Fingers

□

□

1

Pets, animals

□

□

0.5

Breasts, nipples

□

□

0.5

Back

□

□

0.2

Feet, toes

□

□

0.9

Other people

□

□

0.4

Beauty or birth marks

□

□

0.1

Nose

□

□

0.8

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Table I.1  Continued Site

Yes

No

Normative (%)

Ear

□

□

0.4

Neck

□

□

0.5

Stomach

□

□

0.2

Shoulder

□

□

0.1

Chest

□

□

0.2

Bottom, perineum

□

□

0.3

can see all damage present. Some people pull often from one area and others may pull a little from many areas. You should also note that hair is not always pulled from the client’s own body: Pulling the hair of significant others, children, pets, or toys such as stuffed animals or dolls can also occur. In addition to assessing areas of the body from which hair is removed, attempt to understand how the pulling sequence starts and what the client does with the hair after it is pulled. Individuals with TTM may enact a host of hair-​related behaviors prior to the actual removal of hair. Box I.2 describes the most common ones. For each client, attempt to develop an understanding of these behaviors along with the behavioral sequence that leads to the removal of the hair. After identifying the pre-​pulling sequence, determine what the client does with the hair after it is pulled. Post-​pulling behaviors vary widely. Box I.2 also lists activities that the client may do after pulling the hair. Although the list is not comprehensive, it does represent more commonly seen activities. A wide variety of post-​pulling behaviors can occur, but one is particularly important to note: If a client informs you they are ingesting the hair, refer the client to a physician to assess for the possible development of a trichobezoar.

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Box I.2 Examples of Pre-​and Post-​Pulling Behaviors Pre-​Pulling Behaviors Stroking the hair Twisting or playing with the hair Mouthing hair Staring or gazing at the hair Isolating one or two hairs Finding a thick hair Finding a rough or coarse hair Finding a discolored hair Finding a nonsymmetrical (out-​of-​place) hair Post-​Pulling Behaviors Rubbing pulled hair on mouth Placing pulled hair in the mouth Biting pulled hair Listening for the “pop” sound when hair is removed Ingesting pulled hair Rubbing pulled hair between fingers Wrapping pulled hair around fingers Discarding hairs “Popping” root of hair Doing something with the pulled root Examining the pulled hair Saving the pulled hair or part of pulled hair

TTM Severity Measures After assessing the pre-​and post-​pulling behaviors, it is helpful to obtain baseline measures of pulling severity. The following are descriptions of commonly accepted TTM severity measures. The MGH-​HS (Keuthen et al., 1995) is a seven-​question self-​report measure that assesses global hair-​pulling severity. Each item is rated on a scale of 0 to 4, and the total severity score is created by summing the seven items. Total severity scores range from 0 to 28, with higher scores reflecting greater severity. The instrument has been found to have acceptable psychometric properties (Keuthen et al., 1995; O’Sullivan et al., 1995). In addition to the total severity score, the MGH-​HS contains 26

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two factorially derived subscales, one measuring severity (obtained by summing items 1, 2, 4, and 7) and one measuring resistance and control (obtained by summing items, 3, 5, and 6; Keuthen et al., 2007). Recent studies have suggested a decrease of 7 points on this scale reflects a clinically meaningful reduction (Farhart et al., 2019; Houghton et al., 2015). One caveat that should be recognized is that the MGH-​HS is based on a different conceptualization of TTM than the one underlying the AEBT-​T model. As a result, the MGH-​HS includes questions about the degree to which the urges have reduced and how much control the client has over the urge, both of which are seen as signs of therapeutic improvement. In the ACT model, however, the client is discouraged from controlling the urge. As a result, the MGH-​HS can be confusing to the client as they progress through AEBT-​T, and it may underestimate improvement. The NIMH-​TTM scales (Swedo et al., 1989) involve a semi-​structured clinical interview. There is a clinician-​rated scale, the NIMH-​TTM Symptom Severity Scale (NIMH-​TSS), and an overall impairment scale (NIMH-​TIS). The NIMH-​TSS consists of five items assessing time spent pulling, problems thinking about pulling, attempts to resist the urge to pull, general distress about the pulling, and the interference in one’s life created by pulling. The NIMH-​TIS is a 10-​point, clinician-​completed rating scale measuring impairment produced by the time spent pulling or concealing damage, ability to control pulling, severity of alopecia, interference, and incapacitation caused by the pulling. Although few data exist evaluating the psychometric properties of the NIMH-​TTM scales, the interrater reliability scores for the measure have been found to range from .78 to .81. In addition, these scales appear to be sensitive to change in symptom severity because of treatment (Swedo et al., 1989). Recent research has suggested a decrease of 6 points on the NIMH-​TSS is indicative of a clinically meaningful treatment response (Farhart et al., 2019; Houghton et al., 2015). Limitations of the NIMH-​TSS are like those of the MGH-​HS; there are inconsistencies between some items of the NIMH-​TSS and the principles of ACT. Therapists should be aware of these contradictions. The Trichotillomania Scale for Children—​Child and Parent Versions (TSC-​C and TSC-​P; Tolin et al., 2008) are the most commonly used assessment measures for children and adolescents with TTM. This

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measure is validated on youth ages 8 to 17 years. The TSC-​C and TSC-​ P are 12-​item self-​report questionnaires with one version for the child and one for the adult. They each have subscales for severity and distress/​ impairment and a total score. It is a multiple-​choice questionnaire with scores of 0 to 2 per item. The total score is summed and divided by the number of questions in that scale for a score of 0 to 2, with higher scores representing worse symptoms. The measure is valid and has been used in multiple outcome studies. Product measurement reflects another method of assessing pulling severity. In this method, the product of pulling is measured. Products are physical traces that remain because of a behavior. In TTM, common product measures include the diameter of bald spots, rating of the damage from areas of pulling, the number of pulled hairs, or pulled hairs collected by the client and returned to the therapist. Although product measures can be quite useful and informative, you should approach them with caution. It is often quite shameful and embarrassing for clients to let their damaged area be seen by others, let alone measured, and it is often equally difficult for them to collect the pulled hair and bring it to therapy. The upside of these procedures is that they are less likely to be subject to reporting biases, and when regrowth starts to occur, product measurement can be particularly reinforcing. In self-​monitoring, the most common strategy for assessing pulling severity, the client monitors their own pulling. Monitoring can be done contingent on each pulling episode, or globally at the end of each day. In addition to providing a measure of pulling frequency or duration, self-​ monitoring can also be helpful in collecting other data about particular environmental variables that may influence the behavior.

Functional Assessment of Pulling It is important to understand the function that pulling plays for an individual client. Therefore, you should conduct a functional assessment to determine settings in which pulling commonly occurs, emotional states or cognitions with which pulling is associated, and both internal and social consequences that may occur because of pulling, all of which may serve to maintain the behavior. In the following discussion we briefly

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review the various content domains that should be considered in a functional assessment of TTM.

Settings Various settings and activities have been associated with increased frequency of pulling. These include studying, reading, doing homework, watching television, being alone, having leisure time, being in class, and grooming (e.g., Duke et al., 2009). Other research shows that pulling tends to be worse in the evening (du Toit et al., 2001) and when traveling or waiting for something to happen (O’Conner et al., 2003). Likewise, it is not uncommon to hear clients report that pulling most frequently occurs in the bathroom, bedroom, den, or car. Settings in which the client can be alone and in which they are at a period of low activity are often associated with more pulling.

Antecedent Emotional States Researchers have long recognized the association between various antecedent states and pulling severity. Emotional states linked to increased levels of pulling include boredom, tension, and anxiety (Diefenbach et al., 2002). In addition to these more discrete emotional states, it is common to hear clients report a vague urge to pull, an itchy feeling (du Toit et al., 2001), or generally negative affect (e.g., shame) prior to pulling episodes. Research has also shown that pulling can serve the function of decreasing boredom, sadness, anger, and tension (Diefenbach et al., 2008).

Antecedent Cognitions At times, clients may hold specific beliefs and thought patterns that may serve to evoke or maintain pulling if taken literally and acted upon. Examples include beliefs about the inappropriateness of certain hairs (e.g., too thick, too coarse, too gray), thoughts that hairlines should be symmetrical, beliefs that hair pulling is uncontrollable, thoughts

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that if pulling has started it will be impossible to stop, mind-​reading thoughts in which the client assumes others view their appearance negatively, and thoughts that the client is unworthy or unlovable because of their appearance. In a study by Duke et al. (2009), the most common cognitions related to pulling were: it “feels coarse,” it “doesn’t feel right,” it “is curly,” and it “doesn’t look right.”

Consequences of Pulling Various changes in the client’s environment can take place during a pulling episode. Generally, these are divided into internal and external consequences. Internal consequences are those autonomic, tactile, auditory, or cognitive changes within the client themselves that stem from pulling. Examples include reduction of an urge, relief, tension reduction, decreases in anxiety, confidence that the “bad” hair has been removed, tactile sensations stemming from rubbing the hair on the lips or between the fingers, the sound of the hair being pulled or bitten, etc. Clients also report fascination in lining up hairs, sticking them to things, or seeing a certain type of bulb (e.g., large and bloody). External consequences are social reactions to the pulling that may occur. Caregivers or significant others may comment on the pulling, the client may be told repeatedly to stop the behavior, or the pulling activity may disrupt ongoing activities that need to be completed. Appreciating the family dynamics around pulling is important because family functioning is lower in families with a child with TTM versus controls (Moore et al., 2009). Conducting a careful functional assessment focusing on internal and external antecedents and consequences will provide useful examples throughout treatment, will be helpful in fleshing out the client’s description of their pulling, and will be particularly useful in developing the later trigger reduction procedures described in the therapist guide.

Self-​Report Measures on Pulling Functions In addition to obtaining an individualized functional assessment, two self-​report measures may aid in determining the relative levels of focused (emotion-​controlling) and automatic (habitual) pulling. These

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instruments are described below. Although they are not intended to supplant a good functional assessment, nor are they designed as measures of therapeutic progress, they are potentially useful complementary instruments. The MIST-​A (Flessner et al., 2008b) is a 15-​item scale consisting of two separate subscales. The Focused Pulling Scale consists of 10 items designed to measure focused pulling symptoms of TTM. It has an internal consistency of ∝ =​.77, and higher scores on the focused scale are correlated with greater levels of depression, anxiety, and stress on the DASS-​21 (Lovibond & Lovibond, 1995), along with a greater likelihood to pull in response to physical anxiety, specific bodily sensations, and worry. The Automatic Pulling Scale is a five-​item scale designed to measure the level of automatic pulling. It has an internal consistency of ∝ =​.73 and is inversely correlated with the percentage of pulling episodes in which participants were aware of their pulling. The automatic scale was not correlated with the DASS-​21 subscales, nor was it correlated with one’s self-​reported likelihood to pull in response to physical anxiety, a specific bodily sensation, and worry. Each item on the MIST-​A is rated from 0 (“not true of any of my hair pulling”) to 9 (“true for all of my hair pulling”). Based on a normative sample of 1,697 individuals reporting behaviors consistent with a diagnosis of TTM, mean focused scale scores were 45.4 (SD =​16.2). Mean automatic scale scores were 25.7 (SD =​9.04). The focused and automatic subscales are not significantly correlated, which suggests that they measure separate processes. We have included a copy of the MIST-​A in Appendix A. You may photocopy the scale from the book, or it can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The MIST-​C (Flessner et al., 2007) is similar functionally to the MIST-​A except that it is designed to assess focused and automatic pulling in children and adolescents aged 10 to 17. The MIST-​C is a 25-​item measure with two subscales (focused and automatic pulling). The focused subscale has 21 items whereas the automatic subscale only has four. Scores are determined by summing the items in the individual subscales, with higher scores representing greater “focused” or “automatic” pulling. Available evidence indicates suitable psychometric properties. We have included a copy of the MIST-​C in Appendix A. You may photocopy the scale from

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the book, or it can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The AAQ-​ TTM (Houghton et al., 2014) is an adaption of the Acceptance and Action Questionnaire II (AAQ-​II; Bond et al., 2011; Hayes et al., 2004). We have found that the AAQ-​TTM performs better for tracking psychological flexibility in individuals with TTM than the AAQ-​II (Ong et al., 2019). The AAQ-​TTM aims to measure psychological inflexibility as applied to one’s pulling-​related inner experiences (e.g., thoughts, urges, feelings, emotions, sensations). Psychological flexibility is the core process of change in ACT, and it involves the ability to be present with inner experiences, see them for what they are, make room for them in life, and clarify one’s values and move toward them. It is a metacognitive concept involving one’s reactions to internal experiences. The AAQ-​TTM is a nine-​item questionnaire that is rated on a 7-​point Likert scale (1 =​never true to 7 =​always true). The total score is created by summing all the items, resulting in possible scores from 7 to 63. Higher scores represent higher psychological flexibility (e.g., higher scores are good). The AAQ-​TTM has excellent psychometric properties. We have included a copy of the AAQ-​TTM in Appendix A. You may photocopy the questionnaire from the book, or it can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Comorbid Conditions and Differential Diagnoses As psychiatric comorbidity rates are high in TTM populations (Houghton et al., 2016a), it is important to conduct a good assessment for co-​occurring conditions. Three areas should be considered. The first involves differential diagnosis. Assuming physical causes for hair loss have been ruled out (e.g., alopecia, male pattern baldness), the astute therapist will consider the possibility of various differential diagnoses. Our work found that the most common co-​occurring conditions were excoriation disorder (21%), major depressive disorder (17%), and generalized anxiety disorder (15%; Houghton et al., 2016a). Other clinical issues of note are posttraumatic stress disorder and alcohol or other substance use disorders.

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Three diagnoses occasionally occur as unique rule-​outs: OCD, body dysmorphic disorder (BDD), and a psychotic disorder. Hair pulling as a primary compulsion is rare in OCD, and in the absence of a history of other compulsive behaviors or in the absence of obsessional content, it is unlikely that the pulling is a result of OCD. In individuals who pull, a BDD diagnosis would be considered only if the pulling occurred in reaction to, or as a way to correct, a perceived deficit in appearance. The presence of automatic pulling or pulling for pulling’s sake would clearly argue against a BDD diagnosis. Finally, therapists should probe for the possibility that pulling could be the result of hallucinations (e.g., visual or tactile hallucinations of bugs crawling on or into the skin) or delusions (e.g., beliefs that hairs are conduits for information to be implanted into the brain). Although such symptom presentations are rare, you should be aware of the possibility, as such diagnoses require different treatments. Co-​occurring conditions should also be assessed for how they contribute to the worsening of TTM symptoms. For example, depression is associated with severe TTM, followed by anxiety, but occurrence of both anxiety and depression is associated with the most severe forms of TTM (Grant et al., 2017).

Global Life Functioning The primary area affected by TTM is quality of life. Work has shown that those diagnosed with TTM report lower quality of life than healthy controls (Odlaug et al., 2010). Unlike other disorders such as depression or schizophrenia, in which the target behavior is itself labeled as aversive (e.g., most people do not like the feeling of being depressed), many people with TTM enjoy the pulling. We have heard many clients say, “I would love to pull for hours each night if it didn’t cause these bald patches.” The part of TTM that brings most clients into therapy is the amount of time that pulling takes away from their day, the restriction of activities from having bald spots, and, for many, the guilt and embarrassment that come with pulling. In short, the primary negative result of hair pulling is the difficulty it brings to doing many things that are important in life. It is clinically useful for both the client and the therapist to be aware of how the client’s life is being restricted by the pulling or by avoiding things that occasion the urge to pull. While

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this is formally assessed in the AEBT-​T protocol, there are standardized measures for quality of life that may be useful. We have used measures such as the Quality-​of-​Life Scale (Burckhardt & Anderson, 2003), although we prefer measures such as the Work and Social Adjustment Scale (Mundt et al., 2002) because it is more sensitive to the smaller and slower functioning changes that occur as someone stops pulling.

Assessment Summary The assessment approach outlined in this chapter reflects procedures that can be useful to paint an initial picture of the client’s struggle. Nevertheless, assessment does not end here. Ongoing assessment of pulling reduction is necessary, but perhaps even more important is continual assessment of how the client is functioning globally. Are they doing things they didn’t do before because of the pulling? Are they living a more fulfilling life? If not, this is why people come to treatment, and you should keep this in mind throughout all aspects of therapy.

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CHAPTER 1

Session 1: Trichotillomania (TTM) Education, Therapy Overview, Expectations, and Assessment of Pulling Triggers

Materials Needed ■ Pulling Triggers Assessment Form (PTAF) (see therapist guide Appendix A) Form I: TTM Self-​Monitoring Form (available in both client work■ book Session 1 and therapist guide Appendix B) Form II: Monitoring Your Urge Form (available in both client work■ book Session 1 and therapist guide Appendix B) Therapist Note All forms, graphs, and worksheets can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Session Outline ■ ■ ■ ■ ■

Initiate weekly assessment of progress Provide education about TTM Provide overview of the program Discuss therapeutic expectations Introduce client to habit reversal training (HRT) and strategies for trigger reduction ■ Conduct assessment of pulling triggers Introduce self-​monitoring ■ ■ Assign between-​session work

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Therapist Note Chapter 10 near the end of this therapist guide contains modifications for working with adolescents, organized by session. Refer to that chapter if you are working with this age group.

Completion of Assessment Measures At the start of each session, the client should turn in or complete a weekly assessment. We suggest the client track their pulling on paper or using an electronic log and be ready to discuss it at the subsequent session. As noted in the introductory chapter to this therapist guide, with adults, you should track TTM severity using the Massachusetts General Hospital Hairpulling Scale (MGH-​ HS), and in adolescents, use the Trichotillomania Scale for Children (TSC). Because the client will be doing self-​monitoring regularly, the client can complete the MGH-​HS or the TSC every few weeks rather than weekly. We also suggest giving the Acceptance and Action Questionnaire for Trichotillomania (AAQ-​ TTM), a measure of psychological inflexibility, every three or four sessions, as it changes slowly. Additional TTM assessments described in the introduction can be tailored to suit the client’s needs. It can be useful to plot data regularly from these measures on a graph and review it with the client. Doing so can reinforce clients for their progress, and a lack of improvement can serve as a launching point for discussing difficulties with treatment implementation or client motivation. A blank Weekly Graph of Progress (to track progress over the course of treatment) can be found on page 81 of the client workbook, and a blank Daily Graph of Progress (to track progress over the course of each week of therapy) can be used to plot daily progress as shown on the client’s completed TTM Self-​Monitoring forms. This form can be useful in facilitating discussion about various events related to fluctuations in pulling. You may photocopy the graphs from the workbook, or they can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. TTM Education At the start of Session 1, refer the client to the educational material in Chapter 1 of the workbook. The purpose of psychoeducation is to make 36

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sure the client has a basic understanding of TTM and to let them know they are not alone in experiencing the disorder. Review and discuss all aspects of TTM, including its definition, common areas from which hair is pulled, prevalence and gender differences in TTM, common comorbid conditions, the typical age of onset, patterns of pulling, and genetic and biological factors in the development of pulling. This is also a good time to discuss any cultural or religious issues that should be incorporated into your treatment. Discuss the sometimes-​confusing nature of TTM, that clients often enjoy the pulling but greatly dislike the impact it has on their lives. This dialectic often creates fluctuations in motivation to change. Sometimes clients can be very ready to change their pulling, only to find motivation waning quickly. Finally, review with the client the distinction between focused and automatic pulling (see the introduction in this therapist guide). This discussion will set the stage for the general description of the treatment program.

Overview of Treatment Clients with TTM often have urges to pull, feel pressure in pulling sites, and experience both pleasure and anger from their pulling. Often, pulling has occurred so often, for so long, that many who pull hardly know when it is happening. Many clients see TTM as a clear disorder they possess, but they do not often understand that TTM is actually a set of specific processes and behaviors that, when put together, make up a disorder. During the treatment overview, help the client understand that pulling is a complicated action made up of individual and powerful factors. Because of this, therapy involves unique elements designed to address the factors underlying TTM. The client needs to understand the distinction between pulling-​related internal experiences (urges, emotions, sensory experiences, cognitions) and the act of pulling. The client likely sees therapy as being just about reducing pulling and, in doing so, they often conflate the internal experience (e.g., urge) and act (e.g., the behavior of pulling). Inform them that the first part of therapy focuses on getting the act of pulling under control, and Sessions 3 through 10 will focus on what to do with their urges and other internal experiences that drive pulling. To help separate the internal experiences from the act of 37

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pulling, relevant homework is assigned in Sessions 1 through 3. In these assignments, the client is asked to describe their urges to pull and what they do when these internal experiences are present. You will be using this information later in therapy. The following is a sample dialogue on this topic. We generally work on two things in therapy: helping you control your pulling and handling your urges, thoughts, or other drives to pull when they show up. But to do this we need to discuss something that many clients are not aware of: Urges to pull and the act of pulling are separate things. Usually, clients report a need to pull, a tingle, or some pressure in a particular area of their body, or a sense of boredom or frustration that is regulated by pulling. But in their day-​to-​day lives, these inner experiences and the act of pulling occur so tightly together they see it as one thing: trichotillomania. Just like hunger and eating, urges to pull and pulling are separate events, even though they commonly occur together. Because they are really separate events, we will use different strategies to respond to each of them. When someone pulls in response to certain emotions or urges, we generally call that focused pulling. Others find they pull while watching television or driving. They pull outside of consciousness. We call this automatic pulling. Some people have a more intentional or focused style, and others have a more habitual or automatic style, but most people have both. For that reason, we won’t spend too much time worrying about whether a particular episode is focused or automatic. We’ll simply do the treatments that were developed to address the different styles most people share. The first part of therapy deals with helping you get some control over the act of pulling. As you work on stopping your pulling, you will find that your internal stuff will go up and down. Beginning in Session 4, we will work on the struggle with your inner stuff and the ways that you respond to these experiences. Many therapists who treat TTM would work with you to change or regulate your pulling and your urges to pull at the same time. They may try to find other ways you haven’t considered to help reduce your urges to pull. These are certainly potentially viable options. Many people with TTM try this approach. Some find it useful, and some do not. If you’ve tried it, I’m guessing that it has not worked out for you

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because you are still looking for help with your pulling. This treatment is not about giving you one more way to try and reduce the want to pull—​ it’s different. Starting this week, I’m going to ask you to start tracking your internal experiences that drive you to pull and what you do with them when they show up. I am going to ask you to just do what you normally do when your internal stuff shows up, and I really want you to pay close attention. We will use this information in Session 4. It is often wise to get the client to commit to a course of treatment and agree not to measure progress impulsively. The full benefits of treatment will likely be seen after both automatic and focused pulling are targeted. Although the strategies used to reduce the act of pulling are standard forms of behavior therapy, our work around addressing urges and other inner experiences involves an acceptance-​based approach that teaches clients to function with, rather than regulate, internal experiences. This way the client can behave however they choose regardless of the frequency or intensity of pulling-​related internal experiences that have driven prior pulling. You may use the following sample dialogue with the client: In this treatment, you and I will work as a team. Whenever you learn to do something new, it can be tough and frustrating at first, but there is a nice payoff at the end. Remember when you first learned to ride a bicycle? You fell over and over again. You scraped your knees, bumped your head, and bruised your arms. You had to think about every move you made as you tried to balance and keep pedaling. But eventually, you learned to ride. You were able to go riding with your friends and maybe you are still into cycling. Therapy is like that. It is tough and demanding, but we are doing it because it is important to you; your hair pulling has likely been holding you back quite a lot from other things. During treatment, you’ll fall, you’ll feel a bit confused, and you’ll probably get frustrated at times, but I hope it will provide you with something important at the end. Like most good things in life, success in treatment is not easy to achieve; it will take work. I tell you this because I’d like you to commit to working hard for the 10 sessions we have planned. Let’s push ahead for that amount of time no matter what—​even if you really want to quit. Then we will stop and look at your situation. If at that time it looks as though we aren’t making progress, we will do something else.

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Tempering Therapeutic Expectations Discuss with the client their expectations for treatment. Clients should understand that Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-​T) is not a cure for the disorder, but rather involves learning a set of strategies that will help them more effectively manage their condition. Discuss with your clients the typical response to treatment. The client should understand that TTM can often be difficult to treat, as many clients are torn between enjoying the act of pulling and disliking the impact pulling has on their life. Highly motivated clients often see rapid gains, whereas progress in those who are less motivated may be slower. Clients should also understand that struggling to maintain therapeutic gains is common and simply reflects the difficulty in treating TTM but does not reflect poorly on their efforts. Clients should also understand that because TTM is chronic, occasional treatment booster sessions may be needed. This can be described as follows: Before we begin, I think it’s worth talking about expectations for treatment. The truth is, trichotillomania is difficult to treat. Often people with TTM really dislike the impact pulling has on their lives, but actually enjoy the act of pulling. This can make motivation to stop pulling difficult. Even if people really would like to get better, for some people the act of pulling still calls to them so loudly they find it difficult to use the skills they learn in treatment. We see many people get better initially, but some have a difficult time maintaining their gains. For that reason, you should really look at our work together over the next 10 weeks as the beginning of a journey. You will learn these skills that you need to manage your pulling over this time, but you will likely have to come back as your pulling occasionally reappears. This should not be seen as a failure of treatment or failure of your efforts, but rather as a way you have to manage a very difficult-​to-​treat condition. Even though TTM is particularly difficult to treat, we believe that motivation to change is a key to success. Motivation is especially difficult to create; it usually comes after success rather than before. Therefore, we need to find ways to keep engagement even when

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motivation is down. Our assumption is that motivation will go back up after successes occur. I know I just told you that stopping pulling is going to be difficult, but I also want to remind you that people who really engage with treatment have a great chance at success. It can just be hard to stay engaged the whole time. I suggest you behave “as if.” Behaving “as if ” means you engage in all this work with me as if you are going to stop pulling. Come into each session and work with me as if the information you are learning will help you. Go home and practice as if it is going to help you stop pulling. Sometimes I think of an athlete who is playing poorly, or their team is way behind. Some athletes keep behaving as if they can win. And do you know what? Sometimes they do. But if they don’t behave as if they can win, they will lose. If you approach this treatment as though it probably won’t work, it probably won’t. Engage with me as if this has a shot at working, even when you are not feeling it, behave as if you can stop pulling. If you do this, you have a much better shot.

Introduction to HRT and Trigger Reduction Procedures Introduce HRT to the client as a technique that is useful in stopping the act of pulling. You may use the following sample dialogue: Next session we’re going to start a piece of the treatment that was developed to help you stop pulling. This part of treatment involves learning two skills. The first is called habit reversal. Habit reversal will bring the pulling more into your awareness and give you a way to stop it. Also provide the client with a rationale for strategies for trigger reduction: The second skill is called trigger reduction. The purpose of trigger reduction is to find things that make pulling more difficult for you to do. We know that when behavior becomes more difficult, it happens less. So, our goal in trigger reduction is to come up with relatively simple strategies in your life that you can use to make your pulling more effortful. At this point, I’d like to discuss with you the various situations that make your pulling more or less likely to happen.

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Assessment of Pulling Triggers Using the Pulling Triggers Assessment Form (PTAF) and corresponding Completion Instructions located in Appendix A of this therapist guide, engage the client in an assessment of the different situations that make pulling more likely. (You may photocopy the form from the book, or it can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.) Pay specific attention to those settings or items that can be altered in the future. It is useful to talk about this during this session so that the client can pay attention to their pulling and come to the next session with more pulling triggers. End the session by introducing self-​ monitoring, assigning pulling monitoring, and telling the client that the next session will involve the implementation of HRT and strategies for trigger reduction.

Introducing Self-​Monitoring Throughout the course of treatment, the client will be asked to monitor their pulling. This is intended to serve two purposes. First, it will provide ongoing data to the therapist on results of the treatment. Second, it will keep the client invested in the therapeutic endeavor. To introduce the monitoring for the first week, the following could be said: From now until the end of treatment, I’m going to ask you to monitor your pulling for me. During the next week, I’d like you to use Form I: TTM Self-​Monitoring Form in the workbook to record any pulling you do during the day. Before you go to bed each night, I would like you to record how much time you spent pulling each day; describe the situations in which your pulling occurred; and describe the common thoughts, emotions, and urges you had before and after you pulled. I’d like you to bring the completed form back to me at our next session. Do you have any questions? I’d also like you to complete Form II: Monitoring Your Urge Form. To do this, I’d like you to note three times each day when you had an urge to pull your hair. For each of these times, please write down what you did to deal with the urge, if you did anything. At the next session, I’d like you to bring the completed form back to me. Keep in mind that we are just 42

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paying attention to this part of your trichotillomania; we are not going to do anything with it at this time. Do you have any questions?

Between-​Session Work ✎ Instruct client to monitor hair pulling on a daily basis using Form I: TTM Self-​Monitoring Form in the workbook. Instruct the client to complete Form II: Monitoring Your Urge Form ✎ in the workbook on a daily basis over the course of the next week.

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CHAPTER 2

Session 2: Habit Reversal Training (HRT) and Trigger Reduction Strategies

Materials Needed ■ Worksheet 2.1: Pulling Signals (available in both client workbook Session 2 and therapist guide Appendix B) Worksheet 2.2: Trigger Reduction Strategies (available in both client ■ workbook Session 2 and therapist guide Appendix B) Form I: TTM Self-​Monitoring Form (available in both client work■ book Session 2 and therapist guide Appendix B) Form II: Monitoring Your Urge Form (available in both client work■ book Session 2 and therapist guide Appendix B) Therapist Note All forms, graphs, and worksheets can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Session Outline ■ ■ ■ ■ ■ ■

Conduct weekly assessment of progress Inquire about any reactions to material from previous session Review between-​session work Implement HRT Recommend specific trigger reduction strategies Agree on between-​session work

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Therapist Note Chapter 10 near the end of this therapist guide contains modifications for working with adolescents, organized by session. Refer to that chapter if you are working with this age group.

Completion of Assessment Measures As in every session, the client should return or complete an assessment to gauge progress. This progress (or lack of it) and the client’s reactions should be discussed. Help the client plot assessment data on the Weekly Graph of Progress, provided on page 81 of the client workbook.

Review of Previous Material Answer any questions the client may have about TTM or the treatment program.

Review Between-​Session Work Review the client’s completed Form I: TTM Self-​Monitoring Form from the preceding week. Give praise for doing the homework and point out the importance of continued monitoring. Plot the self-​ monitoring data on the Daily Graph of Progress (provided on the last page of each chapter in the workbook) to examine fluctuations in pulling. Discuss patterns and trends in the data. For example, the client may report more pulling in the evening before going to bed or more pulling following stressful days at work or school. They may report having thoughts that a particular type of hair needs to be removed. Such information can be useful in understanding how the pulling works for that client. Give the client an opportunity to acknowledge any reactions about pulling.

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Habit Reversal Training Inform the client that today’s session will focus primarily on learning to break the habit of hair pulling by using a procedure called habit reversal training (HRT). Remind them that a large part of why people pull is because the behavior has become a habit. A habit is something that happens unconsciously and is triggered by something in the environment. We try reducing pulling triggers because it makes the pulling less likely to start. However, we cannot eliminate all triggers. In these cases, we need a strategy for stopping a habit as it is starting. HRT does this in two ways. First, in HRT people learn to be more aware of their pulling through awareness training. Remember, pulling often occurs unconsciously, so helping a client be more aware of the behavior makes that behavior easier to control. Second, through competing response training, the client is taught a specific skill to stop their pulling habit from continuing. Below, we describe how to implement these two elements of HRT.

Awareness Training The purpose of awareness training is to help the client recognize and react to episodes of pulling or subtle signs that pulling is about to start. Provide the client with a rationale for awareness training prior to its implementation. An example of a rationale follows: In HRT, you first learn to know when you pull or are about to pull. We are going to do some practices to increase this awareness. Because the rest of the treatment depends on you knowing exactly when pulling is about to happen or has happened, this is a very important part of the treatment. Awareness training involves describing the sensations and behaviors that are involved in the pulling episode and acknowledging real or simulated pulling exhibited by the client. Each of these specific procedures is outlined here.

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Describing the Pulling Episode Start by having the client give a detailed description of the entire pulling episode. A good description will include actions the client takes before the actual act of pulling (e.g., hands begin to move up toward the scalp or other pulling site; stroking of the hair, searching for the “right” hair); the act itself (e.g., isolating one hair, and plucking it out about 1 inch above the root with a thumb and forefinger); and any post-​pulling behavior (e.g., stroking the pulled hair across the lips, rolling the pulled hair between the fingers, dropping the hair on the ground). When describing the actions that precede the act of pulling, it can be helpful for the client to frame these as “warning signs” or signals that inform them the pulling is about to occur. The topic could be introduced as follows: To be really aware of a problem, you need to know when it’s happening and when it’s about to happen. In the case of pulling, your body is probably sending you signals, or “warning signs,” before you pull to let you know that pulling is about to start. What I want you to do next is to really think about these signals. These can be things you do or things you feel. There may be several warning signs, such as bringing one’s hand toward the head, sitting in a specific position, stroking the hair, or searching for the “right” hair to pull. In addition, there will likely be private warning signs, such as an urge to pull or a thought about the appropriateness of a particular hair for pulling. Using Worksheet 2.1: Pulling Signals, work with the client to establish one to three different warning signs they experience. This worksheet can be found near the end of Chapter 2 in the client workbook or in Appendix B of this therapist guide, and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. If the client denies experiencing warning signs, point out a few of the examples listed previously and ask the client if they experience any of these signs. Next have the client describe the actual act of pulling in as much detail as possible. You should have the client describe what happens during the act of pulling and also pay attention to the position of the fingers, the arms, and the head, or other area of the body from which the hair is

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pulled. Also encourage the client to consider sensations in the body as pulling occurs. Such sensations could include muscle tightness, pressure in the fingertips, or pain in the area of pulling. After the client has described warning signs and the actual act of pulling, ask them what they do with the pulled hair after it is removed from the body. Ask them to explain and describe in detail the actions associated with post-​pulling behavior. This effort at describing pulling can be enhanced by having the client simulate a pulling episode, watching a video of themselves doing the behavior, or looking in a mirror while pulling. If the client fails to describe a key feature of the pulling, be sure to point this out. Continue to elaborate on the description of pulling until you feel that the pulling and any associated behaviors have been described in sufficient detail.

Acknowledging Self-​Pulling The purpose of this procedure is to help the client acknowledge pulling as it happens in real time. In this procedure, the client will be asked to acknowledge occurrences of their own pulling as they are sitting in session with the therapist. The most difficult part of this procedure is getting the client to pull. Often the client does not pull during sessions. In such cases, ask the client to simulate their own pulling and warning signs. The procedure can be introduced as follows: Now we’re going to practice being aware of the pulling and the warning signs. You need to be aware of these things because they will let you know when you are pulling or about to pull, and it will allow you to do something about it. During the next few minutes of our discussion, as soon as you either pull or do one of your warning signs, I want you to raise your finger. If you notice correctly, I’ll say “good job,” but if you either start to pull or do one of your warning signs and don’t raise your finger, I’ll remind you. Continue this exercise until you feel the client can successfully acknowledge their pulling episodes and warning signs. When the client correctly

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identifies the pulling or warning sign, provide praise for correct acknowledgment. If there are instances when the client pulls or does a warning sign during therapy but does not acknowledge it, be sure to let them know that pulling or a warning sign has just occurred. In some cases, the client is unable to demonstrate awareness of their pulling using the aforementioned procedures. In such cases, you may choose to simulate the client’s pulling and ask the client to identify when you engage in pulling. This can be easier for clients who have difficulty acknowledging their own pulling. Similarly, a client may be asked to watch a video of themselves or someone else engaging in pulling and be asked to identify when the pulling is about to occur. If the client must use these ancillary awareness techniques, it is important to remember that the ultimate goal is to get the client to detect their own pulling in real time. Upon completion of the awareness-​training procedures, the client is ready to begin the primary component of HRT: competing response training.

Competing Response Training Competing response training is at the center of HRT. A competing response is a behavior that has three characteristics: ■ First, it is physically incompatible with the pulling. When the client is faithfully doing the competing response, they cannot be pulling. Second, it is something that the client can do easily in almost any ■ situation. Third, it is something the client can do that is not noticeable to ■ others. One of the most common competing responses for hair pulling (and the one we used in our studies of this treatment program) involved asking the client to put their arms down at their sides and gently clench their fists for 1 minute whenever their hands started to go toward the target pulling area or when they experienced the urge to pull. Other examples of competing responses for pulling include folding the arms together or folding the hands. One mistake therapists often make is choosing a

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competing response that requires the client to have something on them or with them in order to do the competing response. For example, it is logical to ask that a client squeeze a stress ball as a competing response, but clients do not always have such objects with them. A better solution would be to give the client one competing response that does not require them to possess anything. Of course, the chosen competing response may have to be modified for certain situations. For example, if one is driving, it would be dangerous to hold both hands down at the side. In such cases, modifications can be made to do the competing response with only one hand, or to clench the steering wheel with both hands. When introducing the concept, be sure that the chosen competing response is acceptable to the client. Forcing the client to agree to unacceptable competing responses often translates into poor treatment compliance. One way of introducing the competing response phase and asking about its acceptability is as follows: We’re now at the main part of HRT. We’re going to learn something called the competing response. In here we’ll call these your “exercises.” The purpose of these exercises is to teach you to do something to prevent your pulling from happening. After you do this long enough, it becomes very natural and the pulling decreases. I’ll show you the exercise in a few minutes. Basically, you will be expected to do this exercise for 1 minute each time you pull or notice one of your warning signs we talked about earlier. Then demonstrate the chosen competing response. Well, you’ve seen the exercise you’ll be expected to do. Remember, you’ll be asked to do this for 1 minute each time you pull or notice a warning sign. Before we continue, I want to make sure that you’re willing to do this exercise. I know the exercise may not yet feel natural, but you will get better at it. Right now, I’m wondering if you think it will work for you when you really have to do it. Do you foresee any situations in which the exercise will be impossible, or you won’t be willing to do it? Discuss with the client any concerns they may have about using a competing response. Work with the client to develop strategies for addressing these concerns. If the problems with the chosen competing response are insurmountable, choose another.

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Teaching the Competing Response Teach the client to implement the competing response for 1 minute, contingent on occurrences of pulling or warning signs. Demonstrate how the competing response should be implemented. Well, you’ve seen me do this, so now it’s your turn. We’ve already reviewed the exercises and you seem to be doing that very well. Now, we need to use the exercises to stop your pulling. Remember, the two times you are to use your exercises for 1 minute are (1) as soon as you pull and (2) as soon as you notice one of your warning signs. As soon as either one of these two things happen, you should stop and begin your exercises. What I’d like you to do is to pretend to pull and then do the exercise for 1 minute. After that I’ll ask you to go through each of your warning signs and show me how you would do the exercise. Ask the client to demonstrate the competing response after simulated pulling and warning signs. If they do this correctly, be sure to offer praise and encouragement. However, if you recognize that the client is doing something incorrectly, provide corrective feedback.

Using HRT Describe to the client how HRT procedures should be implemented. This involves doing the competing response contingent on any of the warning signs and/​or when the pulling has already started. The competing response should be done for 1 minute. If the pulling or warning sign recurs immediately after the minute is up, the competing response should be done for another minute. New clients often feel they are continuously doing the competing response, which can lead to frustration. Warn the client about this possibility. But also remind them that this frustration is telling them they are learning something new, and their body is getting used to not pulling. Also, caution the clients about becoming complacent with their gains. When clients start seeing improvement, they may become less vigilant about implementing the exercises.

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Recommending Strategies for Reducing Pulling Triggers The Pulling Triggers Assessment Form (PTAF) was completed during Session 1 of Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-​T). Based on the information obtained during the PTAF, specific recommendations for reducing TTM triggers should be made in Session 2. Recommendations for reducing TTM triggers should be individualized for the client. As such, Table 2.1 provides a list of possible strategies that could be used if particular settings, tools, or presence of others Table 2.1  Trigger Reduction Strategy Recommendations Setting

Possible Intervention

Bathroom

1. Keep the bathroom door open. 2. Remove bright lights from the bathroom. 3. Use a timer to limit amount of time in the bathroom.

Watching TV or playing video 1. Sit in the middle of a couch or on a chair with no armrests. games 2. On top of the television place a timer that you must reset by getting up every 10 minutes (to increase effort to stop and start pulling). 3. Hold a furry object or stress ball in your hands. Reading

1. Sit in the middle of a couch or on a chair with no armrests. 2. Hold book with both hands. 3. Hold a furry object or stress ball in one hand and the book in the other.

Bedroom

1. Keep the bedroom door open. 2. Lie in bed only when you’re ready to sleep. 3. Remove chairs with armrests. (continued)

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Table 2.1  Continued Setting

Possible Intervention

Use of tweezers, needles, safety pins, or sharp objects

1. Remove these objects from the house and from your purse.

Use of mirrors

1. Remove magnifying mirrors or lighted mirrors. 2. Remove small mirrors from your purse. 3. Cover mirrors in the bathroom. 4. Limit use of mirror to 1 minute.

Presence of others

1. If pulling does not occur around others, try to recruit social-​ support people to be present in high-​risk situations. 2. If pulling results in attention from others, think of ways to limit pulling in those situations.

Tactile stimulation

1. If the feeling of pulling on the fingertips appears to keep you pulling, you could wear gloves or Band-​Aids to cover the fingers.

is endorsed. This list is not exhaustive, and therapists and supervisors should feel free to come up with additional interventions. However, these principles should be adhered to when choosing and presenting such interventions so that they are theoretically consistent with AEBT-​T: 1. Strategies for reducing pulling triggers should result in making pulling more effortful, difficult, and problematic. This may result in the prevention of the pulling. 2. For the purposes of AEBT-​T, strategies for reducing pulling triggers should not be done to prevent or avoid the emergence of uncomfortable urges, feelings, or thoughts. Such strategies are counterproductive to the AEBT-​T model. 3. The strategies for reducing pulling triggers should be simple, easy to implement, and, when possible, not socially disruptive. After you and the client together select the individualized strategies for reducing triggers on Worksheet 2.2: Trigger Reduction Strategies, review them with the client. (This worksheet can be found near the end of Chapter 2 in the client workbook or in Appendix B of this therapist

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guide, and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.) As an example, assume a client is more likely to pull her eyebrows when in a brightly lit bathroom, removing makeup from her face, and standing very close to the mirror, but to pull her scalp hair while reading books. In this case, to make eyebrow pulling more difficult, instruct the client to remove her makeup in a different room, with less lighting, while standing further away from the mirror. Clients who use hand-​held mirrors, compacts, or tweezers to facilitate pulling may be asked to discard or give away these items. To make the scalp pulling more effortful, the client may be encouraged to use audio books, read while wearing mittens, or hold the book with both hands. You may have to be creative in devising ways to alter various triggers. Be careful not to make these strategies too difficult, or compliance may be lower. Remember, none of these things should be done with the intention of eliminating, reducing, or preventing the urge to pull (though this may happen). Rather, strategies for reducing triggers should only be done to make pulling more difficult.

Between-​Session Work ✎ Instruct the client to continue monitoring hair-​pulling episodes and what the client does with their urges to pull over the course of the next week using Form I: TTM Self-​Monitoring Form and Form II: Monitoring Your Urge Form in the workbook. Ask the client to engage in a competing response whenever they pull, ✎ are about to pull, or experience one of the warning signs. Have the client begin using the trigger reduction procedures fol✎ lowing Worksheet 2.2: Trigger Reduction Strategies.

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CHAPTER 3

Session 3: Increasing Motivation for Treatment Through Values

Materials Needed ■ Worksheet 3.1: Living the Life you Really Want (available in both client workbook Session 3 and therapist guide Appendix B) Worksheet 3.2: Tombstone/​Birthday Party Toast (available in both ■ client workbook Session 3 and therapist guide Appendix B) Form I: TTM Self-​Monitoring Form (available in both client work■ book Session 3 and therapist guide Appendix B) Form II: Monitoring Your Urge Form (available in both client work■ book Session 3 and therapist guide Appendix B) Therapist Note All forms, graphs, and worksheets can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Session Outline ■ ■ ■ ■ ■

Conduct weekly assessment of progress Inquire about any reactions to material from previous session Review between-​session work Discuss values Discuss between-​session work

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Therapist Note Chapter 10 near the end of this therapist guide contains modifications for working with adolescents, organized by session. Refer to that chapter if you are working with this age group.

Completion of Assessment Measures As in every session, the client should return or complete an assessment to gauge progress. This progress (or lack of it) and the client’s reactions should be discussed. Help the client plot assessment data on the Weekly Graph of Progress, provided on page 81 of the client workbook.

Review of Previous Material Ask the client to share thoughts on and reactions to the topics discussed in Session 2.

Review Between-​Session Work Praise the client for engaging in the self-​monitoring process, using the competing response, and implementing the trigger reduction strategies as outlined in the previous session. Highlight the importance of continued monitoring and practice of the competing response and trigger reduction strategies. Plot the self-​monitoring data on the Daily Graph of Progress (provided on the last page of each chapter in the workbook) to examine fluctuations in pulling. Discuss any patterns and trends in the data and ask the client why they think certain trends in the pulling may have developed (e.g., “Why do you think you pulled so often that day?”). With the aid of the completed Self-​Monitoring Form, ask the client to comment on what happened to thoughts, urges, and feelings about pulling when using the competing response. Be sure to note the answers to these questions as client responses may become useful information in later sessions. Remind the client that they are only gathering

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information on private experiences (e.g., urges, thoughts, cravings, etc.), and they are addressed more fully later in therapy. If the client did not comply with the homework or refused to or was unable to use the competing response or trigger reduction strategies, explore barriers to compliance. Stress the importance of compliance and formulate a plan to ensure success with future assignments.

Clarifying Values Although having hair and not pulling may be important to clients, these factors are usually not things clients value most in their lives. Clients often value things like being a good caregiver, spouse, or friend; being a great employee; being there for others; or being a good listener. Nevertheless, the immediate rewards produced by pulling often outweigh the delayed rewards that come from behaving in a way that is more consistent with the aspects of life clients most value. In treatment, we need to spend time identifying and clarifying what the client really values in their lives, and then help them bring this into the present. We want the client to be aware that stopping themselves from pulling in the moment can later result in a fuller head of hair, less struggle with TTM, and, more importantly, the benefits that come from being fully engaged in a values-​driven life. Having values as motivators is important because you will be asking clients to make room for various sorts of discomfort and to forgo pleasurable feelings in the service of something else later. If we are to be successful in the long term, that “something” has to be more powerful than the immediate reward that comes from pulling. The more real and meaningful it can be, the more reinforcing it will be. We want that “something” to be what the client holds in their mind as they choose actions that have long-​term benefit, and help them through possible feelings of discomfort in the short term. In Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-​T), we call that “something” values. Values are things that are important to a person, things a client would be willing to work toward in the face of uncomfortable inner experiences. Values are different than goals. Goals are short-​term and temporary, and ultimately there is an end to the goal when it is completed. Stopping

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hair pulling is a goal, but not a value. Being a loving, caring, and supportive spouse or partner is a value. Being there for your children and supporting them is a value; helping them with their homework is a goal. Goals can be steps toward enacting values, but values can never be fully achieved. When discussing values with the client, recognize that values can be easily translated into goals toward which the client is willing to direct their behavior. You might say something to the client such as the following: I know you probably came in here wanting my help to stop your pulling, and I want that too, but I think we both need to realize that stopping pulling isn’t just about growing your hair out; it is about something much bigger. It is about getting your life back. It is about doing all those things that you have been waiting for. So, we will work together on stopping the pulling, but we need to be aware that these struggles are larger than pulling. By linking the work we are doing on your pulling to larger, more meaningful things, we can really help motivate you and get you through the hardest parts of treatment. For example, when I don’t feel like exercising, connecting with my wishes to be healthy into my later years helps motivate me and keeps me going when I’d rather stop. The client has likely come to therapy to reduce pulling, and this is likely important to them because pulling has gotten in the way of accomplishing more important things. For the client, stopping the pulling is usually about getting back into important areas of life. Many people with TTM have restricted social lives or have allowed their pulling to take time away from the things that are important to them. Values link the therapy to these ends. Work with the client to clarify their values and begin to discuss barriers that stand in the way of pursuing these values. People, not just people with TTM, make decisions about their behavior every day. Sometimes, we behave more consistently with our values than at other times. As contradictory as it seems, people often do behaviors that seem to go against their values. Often this is because values-​consistent behavior is rewarded on a longer, more delayed time scale, whereas values-​inconsistent behavior is rewarded more immediately. For example, a person who truly values being a “great spouse,” may find themselves in a shouting match with a spouse, which is a behavior quite inconsistent with being a “great

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spouse.” In this case, the shouting may be rewarded immediately by winning an argument, but such behavior is inconsistent with the person’s values. Similarly, people with TTM often find themselves engaging in behaviors that are quite inconsistent with their values. For example, a person who deeply values being an “engaged caregiver,” may isolate in the bathroom for 2 hours to pull hair while the children are ignored and left to fend for themselves in front of electronic devices. In both cases, the values-​inconsistent behaviors are rewarded immediately (e.g., winning the argument in Example 1; reducing an urge or experiencing feelings of pleasure in Example 2) and thus overpower behaviors that are rewarded by the more distant value (e.g., not trying to “win” in Example 1; choosing to leave the bathroom and instead play with the children in Example 2). In order to make the reinforcing power of the value more effective, you and the client must first identify the value and then repeatedly bring it into the session and into the decision the client makes about whether to pull their hair. Living the Live You Really Want Exercise Refer the client to Worksheet 3.1: Living the Life You Really Want, and help the client work through it. This worksheet can be found near the end of Chapter 3 in the client workbook or in Appendix B of this therapist guide, and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Please be aware that there are many other areas beyond the 10 we provide on the worksheet, so you may cross some out and replace them with ones that better fit the client. Rename any of these areas if they do not fit for the client. Some areas may not match the client at all and covering another area might make more sense. 1. Have the client talk with you about what each of the areas means to them (i.e., define the value). For example, the area “family relations” is often different for clients who are college students versus a client who is a caregiver with children at home. 2. Have the client talk with you about how meaningful each value is. Show openness to whatever answer the client gives. We all value things differently. You are welcome to ask questions if something

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seems off about the way they talk about a value. Sometimes a client will indicate they do not really value something so they do not have to feel the guilt about doing poorly in that area. You do not need to really challenge them, but give them space to talk it through. Rating the importance of values can be emotional because discrepancies between wants and actions become clearer. 3. Have a conversation about how pulling and its outcomes affect the client’s ability to pursue their values. For example, a client might indicate a lack of self-​confidence around dating due to the hair damage from pulling. While it is possible to date with the damage, it is also possible to stop pulling and date with a full head of hair. This is a joy of a values discussion: The client can connect with what it might be like to date with a full head of hair, and that might be exciting to them. If they can keep this reinforcer in mind, they might be more likely to work toward this value. Discuss across the values. 4. Ask the client to pick out a couple (two or three) values that really stand out and motivate them. Use those values throughout therapy to motivate engagement.

80%/​20% Focus To help the client see why we are spending this time talking about defining and following values, it is worthwhile to contrast that with following emotions. In our clinical experience, those who are doing well in life (however that is defined) spend much of the day doing things that are meaningful to them. We are not saying they spend their days doing things that are fun but, rather, they are doing things that are at least somewhat important to them. Their day might involve cooking breakfast, eating it with family, working, exercising, doing homework with a child, grocery shopping, etc. Looking back on the day, the person can say, “It wasn’t perfect, but there were some meaningful events in there.” They likely engaged in some procrastination or emotional control, but much of the day was spent following various values. On the flip side, we see that many of our clients who are doing poorly (again, however you want to define that) spend significant time trying to regulate their internal experiences. Someone might spend a few hours pulling to manage urges, to calm down an emotion, or to achieve a 62

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specific sensation, and another hour checking out the damage, feeling bad about themselves for pulling, and then trying to distract themselves from those feelings. Less of the day is about following values and more is about regulating private experiences. We want to help the client spend more time following values and less time regulating private experiences. You could say this as follows: I have been studying and working on human behavior for a long time, and something I have seen applies to this topic we are talking about. I think we can divide actions into two categories: actions that are aimed at following values, and actions that are aimed at regulating what goes on between our ears. The lines can be fuzzy, but that’s human behavior. If you take my day so far, I got up early to get my kids off to school, exercised for 45 minutes, and I am now here at work. I would say most of those actions are about things I care about. I might spend a little time watching television tonight and that might be about unwinding, so we can say that is about controlling emotion. I have found that having a day that is 80% about following values and 20% about controlling our own private experiences works out well. I find that people with this 80%/​20% balance look back at their days and are pleased with them. I find people who spend big chunks of their days controlling private experiences—​through doing things such as pulling, checking bald spots, reading about pulling on the internet, and so on—​look back and are displeased with how the day went. One of the goals of this treatment is to shift the time you are spending regulating your urges to pull and emotions from pulling, to time spent on things you actually care about. I want to increase your percent of valued actions and decrease your percent of emotional regulation.

Tombstone/​Birthday Party Toast Exercise Use Worksheet 3.2: Tombstone/​Birthday Party Toast, which can be found near the end of Chapter 3 in the client workbook or in Appendix B of this therapist guide, and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Another way to help the client clarify values is to talk about values like they are things one would like to have written on one’s tombstone or included in a toast at one’s birthday party. Thinking about values as the

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things we do, rather than the things we think and feel, can be helpful. It helps the client conceptualize values and the ways we are in the world and what we do for ourselves and others. This is not the only way to think about values, but it can be useful. You may introduce this exercise as follow: I’d like to do an exercise with you. The goal of this is to really think about how you want people to remember you or talk about you. I want you to think about how you impact the world and others. It can also be helpful to think about how others perceive you. One of the benefits of this is that others don’t know what is occurring in your head or how you feel. They only see what you do. Here is the exercise. Using Worksheet 3.2, pretend you could have your main qualities written on your tombstone or presented as a toast at a party. What would you like said about yourself?

Between-​Session Work ✎ Instruct the client to continue to monitor hair-​pulling episodes and reactions to the urges to pull over the course of the next week (using Form I: TTM Self-​Monitoring Form and Form II: Monitoring Your Urge Form), engage in the chosen competing response, and continue implementing trigger reduction strategies. Ask the client to spend time considering the areas of life that they ✎ want to pursue and the ways in which pulling and struggling with urges to pull have taken away from these areas.

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CHAPTER 4

Session 4: Can Pulling-​ Related Inner Experiences Be Controlled?

Materials Needed ■ Worksheet 4.1: Paper in the Shoe Exercise (available in both client workbook Session 4 and therapist guide Appendix B) Form I: TTM Self-​Monitoring Form (available in both client work■ book Session 4 and therapist guide Appendix B) Form III: Behavioral Commitment Form (available in both client ■ workbook Session 4 and therapist guide Appendix B) Therapist Note All forms, graphs, and worksheets can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Session Outline ■ ■ ■ ■ ■ ■ ■

Conduct weekly assessment of progress Inquire about any reactions to material from previous session Review between-​session work Continue discussion of values Introduce concept of long-​term effects of urge control Work on behavioral commitments Assign between-​session work

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Therapist Note Chapter 10 near the end of this therapist guide contains modifications for working with adolescents, organized by session. Refer to that chapter if you are working with this age group.

Completion of Assessment Measures As in every session, the client should return or complete an assessment to gauge progress. This progress (or lack of it) and the client’s reactions should be discussed. Help the client plot assessment data on the Weekly Graph of Progress, provided on page 81 of the client workbook.

Review of Previous Material Ask the client to share their thoughts on and reactions to the topics discussed in Session 3.

Review Between-​Session Work Praise the client for engaging in the self-​monitoring processes. Review and troubleshoot the implementation of the habit reversal training (HRT) and trigger reduction strategies, and point out the importance of continued use of these tools. Plot the self-​monitoring data on the Daily Graph of Progress (provided on the last page of each chapter in the workbook) to examine fluctuations in pulling. Discuss patterns and trends in the data and ask the client why they think certain trends in the pulling may have developed (e.g., “Why do you think you pulled so often that day?”).

Continue Discussing Values Resume the discussion from Session 3 about values. Usually, clients find values discussions to be new and motivating. Give the client a few minutes to talk about their reactions to the values work from last week. 66

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Next, you will move on to working on the relationship with emotional control, pulling, and values. We often find that what really interferes with living a valued life is a person’s tenuous relationship with their own internal experiences. In particular, these individuals often show an unwillingness to maintain contact with unpleasant inner experiences, or they struggle to set aside a desire for a pleasurable sensory experience. Many times, the act of pulling is simply a quick and effective way of alleviating those unpleasant private experiences or obtaining that pleasurable sensory experience; however, it comes at the expense of valued living. This information will be elaborated on in the next section.

Long-​Term Effects of Urge Control Review “Monitoring Your Urge” Forms from Workbook For the last 3 weeks your client has completed a copy of Form II: Monitoring Your Urge Form (one new form per week), where they were asked to pay attention to their urges to pull a couple times a day. Ask the client what they noticed about their urges. For example: ■ ■ ■ ■ ■

What was the urge like for the client? Where did it occur? How long did it stay if they didn’t pull? What happened to it when they pulled? How long did it stay away?

Our goal with those forms was to help the client become more familiar with this feeling that you are going to spend many sessions talking about and working on.

Urges Can’t Be Controlled in the Long Run In this phase of the program, help the client see their struggle with urges, other unpleasant inner experiences, or cravings for pleasurable sensory experiences more clearly. Clarify whether engaging in efforts to reduce these inner experiences works in the long run. Typically, these 67

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strategies reduce urges to pull or satisfy cravings for sensory experiences for minutes or hours but do not work in the long run. These inner experiences often reappear very shortly. Remember the research from the introduction to this guide—​ it is not the urge or other inner experiences that is the problem, but the way that the client responds to that internal experience. The feeling itself is not the issue; it is reducing the feeling through pulling or other means that is the problem. Efforts to reduce or control urges, thoughts, emotions, or cravings for sensory experiences make sense to the client because they work in the short term (i.e., these inner experiences are reduced). However, the long-​term adverse effects of trying to control these inner experiences are often not noticed, because they occur much later. Repeatedly pulling or otherwise controlling these inner experiences takes someone away from their own values-​driven life. In order to help the client see how their attempts to control unwanted internal experiences are ultimately ineffective, discuss the following questions with the client: 1. What does the client do to control their urges to pull, thoughts preceding pulling, or negative emotions surrounding pulling (e.g., pulls, avoids situation that make them want to pull, avoids stressful situations)? 2. How well does this control strategy work in the short term (usually works very well)? 3. How well does this strategy work in the long term, such as for days and weeks? In other words, does the urge return later? 4. What are the costs of these strategies (e.g., loss of hair, loss of time, emotional toll)? 5. Is the struggle with the urge becoming larger or smaller (usually people report larger)? The client’s completed Form I: TTM Self-​Monitoring Form from the first 3 weeks of treatment can be useful in facilitating this discussion. The purpose of this discussion is to help the client see how ineffective attempts at stopping one’s private experiences are and that other means of dealing with these private experiences are needed (i.e., emotional acceptance). One major point you should note when working with persons with TTM is that pulling one’s hair reduces aversive private events

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or increases feelings of pleasure in the short term, but it is generally ineffective and costly in the long term.

Case Vignette 4.1 Therapist: You’ve been struggling with pulling for a long time, but I’ll bet there’s a part of you that worries about giving it up. Client: Yeah, I’ve been doing it for so long, it’s like my hair is always there for me. Therapist: How do you mean, it’s “always there” for you? Client: Well, whenever I feel upset or bored, or get that awful urge to pull, pulling is what takes care of it. Therapist: Would it be fair to say that pulling helps you deal with that unpleasant stuff? Client: Yeah, that would be fair. Therapist: What else have you tried to deal with that mental stuff? Client: Well, I’ve tried all kinds of self-​help books, I’ve tried ignoring the emotions, I’ve tried relaxing, I’ve even tried medications, everything. Therapist: Pulling? Client: Yep, that too . . . and I guess coming here too. Therapist: How have these things worked to get rid of that feeling? Client: Well, pulling gets rid of the urges and makes me forget about my stress for a little while. Therapist: Does it last? Client: I guess not. Therapist: Tell me about how long you can keep the urge away. I mean, if you really tried hard. Client: I can only keep it away for a couple minutes. I see something or think of something, and it is back. Therapist: It is almost as if the more you try, the bigger it gets. Client: Yes. Therapist: So short term you are pretty good at it, but long term is a different issue. The urge always comes back. If you pull one night and the urge is completely gone, it will be back the next night, right? Client: Yes, there is never a day I go without the urge.

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Therapist: But you work hard at controlling it. Client: It is like a full-​time job—​worse, actually: You get breaks from full-​time jobs. Therapist: Then let’s look at this urge over the years. Do you find that it is getting bigger or smaller? Client: It’s getting bigger. Therapist: OK, we are on to something here. This urge can only be controlled for minutes and hours, not long meaningful periods of time like days and weeks, and it seems to be getting bigger over time, not smaller. This is good information. We need to know how this works. We also need to look at the costs of trying to control these urges. The basic reason you pull is to reduce this urge that you have to pull your hair. The basic reason you avoid stressful situations is because they will make you have the urge. You skip lots of activities because it makes you want to pull. How much of your life is dedicated to controlling these urges to pull? Client: Most of it. It is sort of sad. Therapist: Let me wrap this up for you a little. You spend most of your time trying to control your urges, but they never go away for any meaningful periods of time. Actually, they are getting stronger every year. Finally, all the things that you are doing to control these urges are affecting your life in very significant detrimental ways. It sounds like this is a bad setup. You are playing a rigged game. Maybe the reason you can’t control these urges is that they are not controllable. It is not that you have not tried hard enough; it’s because nothing you can do will stop this urge. Maybe it’s time you stopped hurting yourself. Client: What? And just live with this urge? Therapist: Let’s face it. You are living with it now. You can live with it and pull and fight or live with it without the pulling and fighting. Remember, you have been fighting with it and it has been getting stronger, not weaker. Continue with this discussion until the client begins to see that their attempts at controlling urges to pull and other inner experiences related to pulling are not effective in the long run and are more damaging than useful. If the client does not agree, don’t push it. Send the client home with homework of trying everything they can to keep the urges and other pulling-​related inner experiences under control and then discuss 70

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how effective it was at the next session. The client will not be able to do this because that is not how these internal experiences work. If the client were able to control these private experiences, they would have done so already.

Billiard Ball Versus Bowling Ball One reason the client might struggle so mightily to get rid of the urge to pull is because they view it so negatively. As we will start to cover in later sessions, the urge to pull and the feelings associated with it often show up bigger than is necessary. It is partially because of the fight against them and the unwillingness to interact with them that they feel so large. If the client were to slow down and really interact with that internal experience, they would likely find that it is much more tolerable. We still believe it will never really go away, but maybe it does not have to be so large. We like to explain it as follows: At this point clients sometimes look at me like, “Are you telling me that I can’t control this thing I feel, and I may have to live with this for the rest of my life?” My take on this is that you have to live with some level of urge to hair pull, but not the level we have been talking about. I see you in front of me holding a 16-​pound bowling ball and asking, “I really have to carry this around forever?” No, you don’t have to carry that, but you have to carry some ball. There are other options, the smallest being a billiard ball. A billiard ball is about 6 ounces. It is still notable and solid. It is a bit of a pain to carry around. But it is a much better deal than a bowling ball, yes? Part of what I see is that you are tied up in this urge and fight with it so much that it has become this huge thing in your life. It’s central to your thinking and day-​to-​day living. But if you can manage to step out of the fight against it, I truly believe that you will find that its size shrinks down to something that is less of an issue to carry around. You will never forget about it, like you will never forget your first phone number. But you can find a way to fit that billiard ball into your pocket and carry it around with you. The following two examples can also be used to illustrate what we mean by finding a way to live with the urge to pull. They both illustrate 71

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finding a way to live with something a little difficult and how life might improve if one can do so.

Bully on the Playground The one thing a bully really wants is attention from the person they are bullying. If you are being bullied, fighting back and fussing with the person is what they are looking for. They want to be acknowledged. If you do that, the bullying will probably continue or even get worse. I wonder if your relationship with the urge to pull is a bit like a bully on a playground. It is loud, annoying, and the more you fight against it the bigger it is getting. The thing about a bully is that they can’t see what you are thinking or feeling. You just need to show them that they don’t matter to you. That you are fine with them being around. I think we can do a similar thing with your urge to pull. I think you could treat it like a bully and it will not guide you or push you around. You can act like you are fine with it being there. I doubt you will ever like the urge, much like you will never like a bully. But if we work at it, I bet you can find ways to not interact with the bully. In fact, I’m going to go one step further, and this is the genius-​level bully response. What if you showed kindness and compassion to the bully? I mean, the bully just wants attention and the only way they know how to get it is through this negative action. What if you gave it the attention it needed by inviting it to play basketball with you and your friends, build a snow fort in winter, or hang out and chat at recess? I bet that would really change that relationship with the bully. I wonder if some cool things might happen if you do the same thing with your urges to pull.

Two-​Games Metaphor Case Vignette 4.2 provides a metaphor that should help the client see their options between working to control their urges to pull and working to control the actual pulling.

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Case Vignette 4.2 Therapist: Let me give you an example of what I think has been going on, and you can tell me what you think. You have been playing a tennis match for most of your life, and if you win, your urges, thoughts, and emotions surrounding pulling will go away. If you win, the urges stop. Except there is something that is unfair about this match: You’re playing it against the best professional player on the planet. So, you don’t really do too well. You win a game here and there, but really you keep losing set after set, match after match. The urge just keeps coming back. Your opponent is way better than you, you’re having a hard time beating them, and you’re getting tired of trying. In a way the match is fair. It follows the usual rules of a tennis match, but it is unfair in that you can’t win. Your opponent is the best! This must be frustrating, because if you could win the match, the urges to pull would stop. If you could only win the match, you could lay down the racquet and go and do all those things you have been missing, such as dating, swimming, finding a new job, etc. Does this seem like your situation? Client: Yes. So, what do I do? That is why I am here. How do I control this urge to pull? Therapist: I think you have tried beating it, haven’t you? Client: Sure, I have tried lots of things—​ books, websites, fidget spinners; I even worked with a therapist to learn how to relax. It worked for a while, but the urges got too strong. Therapist: That’s right, and if your pulling didn’t involve any of those urges, emotions, or thoughts about pulling, those things may have been enough. However, in the game of urges, all the books, websites, and relaxation still can’t beat the best. Client: So, what do you suggest? Therapist: Here is my offer. There is another game of tennis over here that most people do not pay attention to. It is like the first game in some ways, but also different in other very important ways. To begin with, this game is fair. It is you playing against someone who is about as good as you. Therefore, the more you put into it, the more you generally get out of it. Most importantly, you’re not playing for whether you have urges;

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you’re playing for the quality of your life. Instead of getting your urges, thoughts, or emotions under control before you move forward, what if we just started moving forward? What if your job wasn’t to win the first tennis match, but to walk away from the match and play a different match—​one where you play for your values? Client: Are you saying that we are not going to work on my urges? Therapist: Listen very carefully. We are definitely not going to do anything that your mind expects with these urges. We are going to do something radically different. Desperate times call for desperate measures. It will be difficult because you will be tempted to look over there and play your old tennis match. I mean, you’ve been playing for a long time, maybe even since your pulling started. But tell me if it isn’t true, that in order to play Game 1 you have to stop doing the other stuff, the stuff that makes your life whole. Client: Sure. I guess it’s true. When I am pulling and trying to satisfy the urges, I am not doing other things. I am usually up in the bathroom with my tweezers, by myself. Therapist: OK, are you willing to look at the idea that you don’t need to win the match with your urges before you start doing other things, the really important things to you? Client: Let’s give it a try. Likely, the client will try to make sense of the metaphor or make a new rule out of it (e.g., “So if I just stop trying to control the urge, then it will go away”). This is common. This is a very different approach to the problem, and the client may have a difficult time understanding at first. If the client does try to create a new rule about how to control the urge, it can be helpful to say something like the following: Maybe, but it sounds to me like you may have just started playing tennis with your urges again. Could that be the case? I know this will be difficult, but for now, I’d like you to keep an open mind about the things we discuss. Try not to figure it out all at once. Refer back to the two-​games metaphor when the client is trying to control their urges instead of doing things that are important to them. We have learned to vary this metaphor based on the sport or competition the client enjoys or understands. 74

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Behavioral Commitments We are going to start actively working on reducing pulling by making weekly behavioral commitments. (See Form III: Behavioral Commitment Form, which can be found near the end of Chapter 4 in the client workbook or in Appendix B of this therapist guide, and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.) This work serves two general purposes. First, reducing pulling is likely the main target that the client noted when they entered therapy. Second, actively reducing pulling provides wonderful opportunities for the client to practice all the techniques we are working on in therapy, including habit reversal, trigger reduction strategies, and Acceptance and Commitment Therapy (ACT) techniques to build psychological flexibility. Stated simply, we want the client to gradually reduce their pulling while utilizing what has been taught thus far in therapy. We will present the necessary aspects of a behavioral commitment in outline form. 1. Make a clear behavioral commitment to reduce pulling. It should be so clear that there is no chance you or the client is confused about what you agreed upon. Any person should be able to rate if it occurred or not. Good examples include the following: pulling fewer than 20 hairs per day, no greater than 20 hairs per day and no hairs one day this week, no pulling after 5 p.m., or no pulling in bed. 2. Make the change so easy you know it will happen. If there is only a 75% chance the client will accomplish it, then make it easier. We want success. Success builds momentum. 3. Link the activity to the client’s values. The client should be clear that this is not about just experiencing discomfort or “doing so because the therapist wants it.” This work needs to be linked to the client’s values; for instance, you might say, “Practicing this will bring you one step closer to having your hair back and the joys that go with that.” Keep this motivator present as you do this work. 4. Practice other aspects of ACT Enhanced Behavior Therapy for Trichotillomania (AEBT-​T). Keep implementing habit reversal training (HRT), trigger reduction strategies, and the ACT strategies covered thus far. If the behavioral commitment is to not pull while in bed (because that is where most pulling occurs), the client should set the bed up for the fewest pulling triggers, make fists whenever the hand goes to 75

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the head, and practice not fighting with urges to pull but rather openly make room for those inner experiences. It is not about “toughing through” these exercises; we want this to be a quality exercise. 5. The client should be ready to adjust the behavioral commitment if something gets in the way. Tell the client they may not come into the next session and say something got in the way. For example, let’s say the client agrees to not pull in bed, but then the family stays in a hotel. Therefore, that challenge did not exist. Hopefully, the client can find another challenge like not pulling in the bathroom instead. We are going to continue this pattern from now until the end of all sessions.

Between-​Session Work ✎ Ask the client to take a half-​sheet of paper (or use Worksheet 4.1: Paper in the Shoe Exercise, provided in the workbook) and write down a private event that they attempt to control through pulling (e.g., the urge, a thought about unevenness in the hair). Instruct the client to fold the paper in half three times and place it between their foot and shoe and keep it there for the course of the week. Do not elaborate on the exercise. Explain to the client that you will discuss the purpose of this experiment at the next session. The client should continue monitoring hair-​pulling episodes over the ✎ course of the next week using Form I: TTM Self-​Monitoring Form. The client should continue to use the chosen competing response ✎ and implement strategies for reducing triggers. Using Form III: Behavioral Commitment Form, the client should ✎ make a behavioral commitment to reduce hair pulling.

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CHAPTER 5

Session 5: Acceptance of Pulling-​Related Inner Experiences

Materials Needed ■ Form I: TTM Self-​Monitoring Form (available in both client workbook Session 5 and therapist guide Appendix B) Form III: Behavioral Commitment Form (available in both client ■ workbook Session 5 and therapist guide Appendix B) Therapist Note All forms, graphs, and worksheets can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Session Outline ■ ■ ■ ■

Conduct weekly assessment of progress Inquire about any reactions to material from previous session Review between-​session work Introduce willingness as an alternative to controlling pulling-​related inner experiences ■ Continue behavioral commitments Assign between-​session work ■

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Therapist Note Chapter 10 near the end of this therapist guide contains modifications for working with adolescents, organized by session. Refer to that chapter if you are working with this age group.

Completion of Assessment Measures As in every session, the client should return or complete an assessment to gauge progress. This progress (or lack of it) and the client’s reactions should be discussed. Help the client plot assessment data on the Weekly Graph of Progress, provided on page 81 of the client workbook.

Review of Previous Material Ask the client to share thoughts on and reactions to the topics discussed in Session 4. If the client was given the assignment to try to prevent the urges or other pulling-​related inner experiences (because they still believed it was possible after the last session), review their efforts and discuss any experiences or insights they may have encountered. When discussing this work, it is possible that the client will have seen new things about urges and want advice on how to fix the problem. These new insights could include certain times and places where pulling is common, certain thoughts that precede pulling, and feelings that coexist with pulling. Our aim is to help the client see that attempts to control the urge to pull only work in the short term and likely exacerbate the urges in the long term, and that attempts to regulate the urge (such as pulling) likely lead the person away from the things that are important to them.

Review Between-​Session Work Praise the client for engaging in the self-​monitoring process. Plot the self-​monitoring data on the Daily Graph of Progress (provided on the last page of each chapter in the workbook) to examine fluctuations in

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pulling. Discuss patterns and trends in the data, and ask the client why certain trends in the pulling may have developed. Review the behavioral commitments made in the prior session. This is a good time to discuss use of habit reversal training (HRT), trigger reduction strategies, and how the client handled pulling-​related inner experiences. Use the success, or lack thereof, to guide the behavioral commitments that will be made for the coming week. Review and troubleshoot implementation of the HRT and trigger reduction strategies. Point out the importance of continued monitoring and use of pulling management strategies.

Accepting Inner Experiences (Willingness) During this session, work with the client on an alternative way of responding to hair-​pulling urges, pulling-​related cognitions, cravings for specific sensory experiences, and emotions that have commonly led to pulling. This alternative way of responding involves learning to be accepting of, rather than controlling of, these experiences. In the previous session the client should have noticed that their strategies to control inner experiences have been largely unsuccessful in the long term and possibly quite costly. Case Vignettes 5.1 and 5.2 provide examples of how to re-​engage in the discussion about the difficulty of trying to control pulling-​related inner experiences.

Case Vignette 5.1 Therapist: Let’s go back to those two games I was talking about last week, the tennis match to control your urges (Game 1) and the other game you were playing for the quality of your life (Game 2). I want to talk about Game 1 and how people get trapped in it. There is a certain assumption in society that if you don’t like something, there is a way to change it. All and all, that is pretty fair to say, because we can change most things we don’t like. For example, if it is cold in the room, you can turn up the heat; if you don’t like your clothes, you can get new ones, etc. But the general rule gets applied to many additional situations . . . maybe 79

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too many. For example, there are many ads on television for different pharmaceuticals that treat all sorts of “problems” such as anxiety, depression, sleep, and sexual urges. I am not saying that these medications are bad—​they have helped a lot of people—​ but they are very much Game 1–​type strategies. If you are feeling depressed, instead of finding things you enjoy, you can “take a pill”; if you are experiencing anxiety, you can “take a pill” instead of learning how to address that emotion. There is a bit of a belief that if our emotions are not at a certain “acceptable” level, we must change that before we can do anything. This is Game 1—​ fighting the unpleasant stuff that shows up inside our own skin. Client: But isn’t it hard to be active when you are depressed? I know that is how I am. Therapist: Absolutely. But in there is the belief that depression must be removed before you can get active. That is the message that society teaches you. How would this apply to hair pulling? Client: If it has to do with urges, it’s probably something like, “My urges have to decrease before I can stop pulling.” The notion that trying to suppress or otherwise placate urges, emotions, cravings, or cognitions related to hair pulling is actually counterproductive can be strengthened through the use of the two metaphors described in Case Vignettes 5.2 and 5.3.

Case Vignette 5.2 Therapist: I want to spend a little more time on this “control” thing. It seems as though we should be able to control the stuff that shows up in our bodies, right? It seems like we should be able to control what we think and the feelings we have. I mean, that is what you have been trying to do with your urges to pull.

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Let’s do an exercise. I want you to put your hand to your head [or wherever the client pulls from] and feel one of your favorite pulling areas. Now I have one simple task: Just don’t get an urge to pull. That is it. [While the client does this, say things that make it more likely that they will get an urge, such as talking about the types of hairs that they enjoy pulling.] How did that work?

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Client: Duh! I have the urge now and I will probably want to pull more at home tonight. Therapist: OK. That was a little difficult. Let’s try a thought. For the next minute I want you to not think about your favorite hairs that you pull. Don’t think about the ones with big roots, that are thicker than the others, etc. [Continue to give little reminders to keep the client thinking about their favorite hairs.] OK. How did that work? Client: This is totally unfair. It is impossible and you are making me want to pull. Therapist: Just to be fair, I am not doing anything that your mind is not already doing. Your mind does this all day long. It tries to avoid the urges and gets pulled into thinking about the “good” hairs. Are you sensing what this struggle does to you? Now, let’s try something different. Please don’t touch that tissue box [or another object in the room]. I want to see if you can go a whole minute without doing that. Client: That’s simple. What an odd request. Therapist: But the task is exactly the same; just don’t do one simple thing. Don’t have an urge, think about good hairs, or touch something. Notice that the first two have to do with thoughts and feelings and the last one is a thing you do. They are different. They work under different rules. You have been applying outside-​the-​body rules to thoughts and feelings. They don’t work there. The outside world works differently than the inside world.

Paper in the Shoe Exercise At this point it is useful to process the “paper in the shoe” exercise (Worksheet 4.1) assigned at the end of Session 4. In the exercise (as shown in Case Vignette 5.3), the tactile sensations generated by the paper in the shoe should be equated to the private event (written on the paper) that the client uses pulling to control. The exercise has multiple purposes. The first is to demonstrate to the client how the “urge” will show up at random. It will be there at times and it will be gone at times; it is not under the client’s control. Likewise, it demonstrates to 81

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the client that if they start interacting with the “urge” by thinking about it, shifting their foot around, trying not to notice it, etc., then the sensation will become more present and the client will be less involved in their ongoing life. Through this physical metaphor, the client should see that the more they interact with an internal sensation, the more salient it becomes. The client should also see that the sensations will come and go naturally, but only if left alone. If interacted with, they will remain present.

Case Vignette 5.3 Therapist: So, last week, I had you put the paper in your shoe. I’m sure that seemed a bit odd. How did it go for you? Client: You’re right: It was a bit weird, but I did it. You know what? It drove me crazy for the first day or so. I was always adjusting my shoe and always moving the paper around. Therapist: So you kept getting involved with the paper and kept noticing it at first. Then what happened? Client: Eventually, I just kind of forgot about it and went about my day. Therapist: What happened to the sensations created by the paper? Were they always there? Client: No, sometimes they were there, but sometimes they went away. A lot of it had to do with how I moved my foot. If I moved it the right way, the sensations showed up. Therapist: So sometimes they were there and sometimes they weren’t. Kind of like your urges. What happened when you started playing with the paper, or moving your foot around to get rid of the sensations? Did you notice the sensations at those times? Client: Definitely. Therapist: So when you tried to get rid of the sensations they were there, and when you left them alone and did other things, sometimes they were there and sometimes they weren’t? Client: Yep. Therapist: I wonder if your urges [or whatever was written on the paper] to pull do the same thing?

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Most of the work in this session has been about helping the client to see that the urge and other inner experiences are incredibly difficult, if not impossible, to control. At this point we hope the client’s dedication to controlling such experiences has lessened, and they see that Game 1 in the two-​games metaphor is unfair and that Game 2 seems like an interesting second option. Offer acceptance of these inner experiences to pull as an alternate option to pulling, as a means of gaining control of their life. Acceptance of private events is a behavioral term that means “not engaging in actions to remove or decrease certain inner experiences.” It involves letting these experiences be there as they are and not fighting with them in any way. It is a choice. It is different from tolerating. It is willfully inviting the unwanted inner experiences, in the same way one would let a less desirable family member stay as a houseguest. Through Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-​T), the client is taught to let their urges and other pulling-​related inner experiences occur and to just observe them. This concept is sometimes difficult to grasp. In the simplest terms, the basis for using acceptance in AEBT-​T is that urges and other inner experiences ultimately cannot be controlled, attempts at controlling them can be harmful, and therefore, we need to make room for them in our lives. We can either have them, resent them every day, and try to get rid of them, or we can willfully invite them in. This metaphor described in Case Vignette 5.4 is a way to present willfully inviting them in and not getting pulled into fighting with them.

Case Vignette 5.4 Therapist: Let’s go back again to those two games I was talking about, the tennis match to control your urges and the other game you were playing for the quality of your life. Let’s pretend that you have agreed to stop playing Game 1 (controlling inner experiences) and will totally focus on the second game (living a meaningful life). How well do you think you would do at Game 2 if you spent part of that game watching the best player from Game 1 play someone else while you were supposed to be playing in Game 2?

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Client: Well, obviously, not very well. You can’t be distracted from the game you’re playing and expect to have a decent chance of winning. Therapist: Yes. In order to do this you really have to completely give up on Game 1. Any time that you get dragged into it is time and effort taken away from the one you have a fair shot at. It will be difficult. You will want to get involved in the other game; you will be curious what the current score is. There might even be moments when you are doing surprisingly well working on Game 1 and want to start playing it a little. Watch out! That might just be the best player trying to pull you into playing Game 1 again. This is an all-​or-​nothing thing. You can’t try it, just like you can’t try jumping off a diving board. You either do it or not. If you want to try Game 2, you have to give up Game 1 completely.

Accepting Urges Does Not Mean Accepting the Pulling At this point in therapy, some clients may get confused about the notion of acceptance. If they have not fully grasped the concept that the act of pulling is distinct from the private events surrounding pulling, then suggestions that a client be more accepting or willing of urges to pull can sound as if the client should just resign themselves to the fact that they pull. If this becomes an issue, you could respond as follows: Remember at the very beginning of treatment, we talked about how it would be important to understand that the act of pulling is different than the urges to pull, thoughts about pulling, or cravings to pull? Since our second session, we have spent some time discussing strategies to control the act of pulling, things like competing responses and trigger reduction strategies. You may have also noticed that when you use techniques to stop the act of pulling, the urge, thoughts, emotions, and craving for certain sensations might come up and even get more intense. That’s why we have been working on being willing to have those experiences. You’ve learned HRT and trigger reduction strategies to stop the pulling, and you are learning other skills to prepare you for the private “stuff” that you were using pulling to control or satisfy. At this point, we’re going to keep using HRT and trigger reduction strategies to stop the pulling, but we’re also going to start using them as tools to help you practice being more 84

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accepting or willing to experience the private events that in the past have led to more pulling.

Pop-​up Ads Thus far we have tried to present acceptance or willingness to have pulling-​ related inner experiences through discussing how well attempting to control those inner experiences works, the billiard ball versus bowling ball illustration, bully on a playground, the two-​game metaphor, and the paper in the shoe exercise. Here we offer one more way to present making room for an uncomfortable inner experience. Imagine you are working on a computer that has poor virus protection and every few minutes another pop-​up ad appears. It’s an ad for something that you don’t really need. You click on the little “close” button and it goes away. But a few minutes later another one shows up. You close that one, too. What if we think about your urges to pull, funny feelings in the pulling area, thoughts about the hairs you like to pull, and so on, as little pop-​ ups? They are kind of like pop-​up ads in that you didn’t ask for them, and frankly, you don’t really want them there. But you don’t need to get into a big thing with them. Just notice they are there, pat them on the head, and push the little close button. I am not saying you can get rid of your inner experiences so easily. What I mean is that your pop-​ups are not you. You don’t need to get into a big thing with them. Just acknowledge they are there and move on. If you don’t get into a big thing with them, you can notice they are there, say “hi,” and move on. Sure seems a lot easier than getting really involved with them.

Behavioral Commitment to Reduce Hair Pulling Work with the client to create another behavioral commitment to reduce hairpulling. (See Form III: Behavioral Commitment Form, which can be found near the end of Chapter 5 in the client workbook or in Appendix B of this therapist guide and can also be accessed by searching for this book’s title on the Oxford Academic platform at

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academic.oup.com.) Use the following points to develop the behavioral commitment: 1. Be specific. 2. Do something that gives the client a high chance of success. 3. Link the commitment to values. 4. The commitment should involve the continued use of HRT, trigger reduction strategies, and acceptance. 5. Make sure the client knows to adjust the commitment if needed.

Between-​Session Work ✎ The client should continue to monitor hair-​pulling episodes over the course of the next week using Form I: TTM Self-​Monitoring Form, engage in the chosen competing response, and implement strategies for reducing pulling. Using Form III: Behavioral Commitment Form, the client should ✎ make a behavioral commitment to reduce hair pulling.

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CHAPTER 6

Sessions 6 and 7: Defusion from Your Inner Experiences: You Are Not Your Urges to Pull

Materials Needed ■ Form I: TTM Self-​Monitoring Form (available in both client workbook Session 6 and therapist guide Appendix B) Form III: Behavioral Commitment Form (available in both client ■ workbook Session 6 and therapist guide Appendix B) Therapist Note All forms, graphs, and worksheets can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Session Outline ■ ■ ■ ■ ■

Conduct weekly assessment of progress Inquire about any reactions to material from the previous session Review between-​session work Discuss defusion from inner experiences Conduct various exercises to show the client what inner events really are—​just inner events ■ Continue behavioral commitments Assign between-​session work ■

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Therapist Note Chapter 10 near the end of this therapist guide contains modifications for working with adolescents, organized by session. Refer to that chapter if you are working with this age group. Sessions 6 and 7 are combined into one chapter because both sessions focus on the topics of defusion. Defusion work can be done in a number of ways. This chapter includes many different exercises aimed at addressing these processes in TTM. They need not all be used but should be used as needed to help the client view their thoughts, urges, emotions, and cravings as nonliteral, ongoing processes that are separate from them.

Completion of Assessment Measures As in every session, the client should return or complete an assessment to gauge progress. This progress (or lack of it) and the client’s reactions should be discussed. Help the client plot assessment data on the Weekly Graph of Progress, provided on page 81 of the client workbook.

Review of Previous Material Ask the client to share their thoughts on and reactions to the topics discussed in the previous weeks.

Review Between-​Session Work Praise the client for engaging in the self-​monitoring process. Review and troubleshoot the implementation of the habit reversal training (HRT) and trigger reduction strategies. Point out the importance of continued monitoring and use of pulling management strategies. Plot the self-​monitoring data on the Daily Graph of Progress (provided on the last page of each chapter in the workbook) to examine fluctuations in pulling. Discuss patterns and trends in the data, and ask the client why they think certain trends in the pulling may have developed. Review behavioral commitment exercises. 88

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Defusion of Inner Experiences Fusion (the opposite of defusion) involves treating inner experiences (e.g., thoughts, feelings, sensations) as much more than they are. Fusion is when one inner experience becomes related to other experiences, and as a result, when the inner experience shows up, in some ways, the other experiences to which it is related also show up. For example, if you ask the client to think of a difficult event they recently experienced, they will not only have the inner experience of thinking about that event (i.e., cognitions), but will likely feel other inner experiences that are associated with those thoughts (e.g., emotions). If the client thinks “sad” thoughts, they will feel some element of sadness. If the event was dangerous, they might actually experience their heart rate increasing. Fusion is when an internal event brings along extra elements that make the event larger and more powerful than it actually is. Fusion is not always bad. For example, if the client has loving thoughts toward their partner, it might be nice to really immerse themselves in the feelings that come along. However, when a client has the thought, “That hair is really weird and it is going to bother me until I pull it out,” strongly feeling all that comes along with that thought only makes it harder to accept and can lead to people choosing to pull. Defusion (the opposite of fusion) involves seeing internal experiences for what they are—​thoughts, emotions, individual bodily sensations, and nothing more. At a technical level, a thought is a set of sounds in our head. Sometimes those sounds tell us something important to do, but at other times they tell us nothing of importance. There are even times when they are harmful if taken seriously. An emotion is just an interesting mixture of cognitions and bodily sensations that we have packaged and given a name. A bodily sensation is only a change in a bodily state; many times it is nothing notable or important. When we experience an inner event from a fused position, we experience these inner experiences literally. A thought about something is experienced like that thing. A worry about a bad future event brings along the emotions of that future event. Instead of feeling the event we call anxiety, it is experienced as “big, horrible or dangerous.” A client with TTM who is fused with their pulling-​ related inner experiences will experience them with monumentally more power than 89

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a client who is defused from them. The feeling of pressure on the head will be experienced as “annoying,” “never-​ending,” and “likely to ruin my day.” In contrast, from a defused position it is just “a pressure.” When fused with the thought “these hairs need to come out,” the person may experience frustration until they are pulled out, versus coming from a position of defusion, in which case “these hairs need to come out” will simply be noticed as “another thought.” Finally, when fused the thought “I bet this one has a great bulb” will bring anticipation until pulled, but from a defused place that same thought is “just another TTM thought.” Defusion is a therapeutic context in which the literality of language is challenged. The purpose of defusion exercises are not to change the client’s thinking from something that is illogical to something that is logical. Rather, it is to change the context of language from something that supports inner experiences as literal events to something that looks at inner experiences as something to simply be experienced. Defusion helps the client to see thoughts, feelings, and emotions for what they are, not for what they present themselves to be. When the context supporting non-​literality is created, the functional impact of these inner experiences on pulling should diminish. Defusion exercises are limitless because there are many ways a therapist can help the client respond to thoughts less literally. Although there are many good examples in other books on Acceptance and Commitment Therapy (ACT), a useful approach to pulling-​related private events is provided here. This session could start out with a discussion about the need for defusion, as illustrated in Case Vignette 6.1.

Case Vignette 6.1 Therapist: I want to talk about your thoughts, emotions, urges, and cravings that sometimes push you into hair pulling. I am not interested in whether these things make sense or if they are accurate or not. I want to talk about the way in which you work with them. When you are pulling hair, what are you usually thinking? What are you usually feeling? Client: I start out thinking that that I probably should not even start, but then I will see or feel a hair that really needs to be pulled out. I will

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usually start pulling and talking to myself about which hairs are the good ones and where I should pull. There is always the end part where I criticize myself for pulling and feel bad about what I’ve been doing. Therapist: After it starts, do you notice yourself thinking about your pulling while you are doing it, or does it just feel natural? Client: After it starts, I just do it. Therapist: Right, most people are not really aware that they are thinking. We just go along day and night with our minds jabbering at us. Our minds talk, describe, criticize, and analyze all day long. This process is really useful when you are at a grocery store looking for ingredients for soup, but this same process really gets in the way when you are looking for good hairs to pull, or when you are trying to talk yourself out of pulling. Your mind is not always your friend. Client: So, what do I do with it? Therapist: The first step is to notice that your mind is always talking to you. Minds are like colored sunglasses that you always wear. You look through them so much that 99% of the time you don’t even know you are wearing them. You don’t know your mind is having a say about everything that happens, everything you see. One part of defusion is the ability to see that a person has thoughts that are separate from themselves and that thoughts and feelings affect the way we experience the world. To help the client see that their mind is always active, they can participate in the following “being present” exercise in session. The exercise should be conducted slowly, while you use a calm tone of voice.

Exercise: Being Present I would like you to do a little exercise with me. It will involve closing your eyes, listening, and following along with what I say. I am not trying to hypnotize you or make you relax. If you get relaxed, that is fine, but it is not my goal. My goal is to help you become more aware that you are thinking. Close your eyes or stare at a blank spot on the wall. I don’t need you to respond—​just listen. I want you to pay attention to your breathing. Pay attention to what each breath feels like as it comes in and what it feels like as it goes back out. 91

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Notice that there is a temperature difference as it goes back out. Notice what your belly feels like as it lowers and rises. Notice who is noticing these things. It is you. Now listen to the different sounds that are in the room. There are the loud, obvious ones like the air in the vents, but there are subtler ones, like the sounds in the hall or outside. See if you can notice those noises. As you listen to these sounds, notice who is hearing them. Here is the real exercise. I want you to watch the thoughts that show up in your mind. Imagine you are sitting in a theater looking at a big, empty stage. The play starts, but instead of actors coming out, your thoughts walk out. Just pay attention to what shows up in front of you as if you were watching a play. See your thoughts out on the stage. There will be some thoughts or feelings that you don’t like that you might want to get rid of. Just notice your desire to get rid of them and continue watching your thoughts on the stage. [Let the client do this for a couple of minutes and gently remind them to continue with the exercise.] If you are having the thought, “I am not sure what it is I am supposed to be doing,” then put that one on the stage. Actors always come and go in plays, so as new thoughts show up, they should go on stage, just as new actors would. When thoughts go, they will leave the stage, just as actors will in a real play. There will be moments when you are no longer doing the exercise and you are only thinking. I call that “buying into a thought.” Just notice the difference between that time and watching thoughts on the stage. If that happens, gently bring yourself back to the exercise and get it going again. Help the client see that their mind does not stop, that it always has something to say. It is likely that they bought into a thought about a particularly difficult topic, such as hair pulling.

Conduct Defusion Exercises The Mind Does Not Stop Talk to the client about how the mind grabs on to certain topics. It can be helpful to show this by starting a sentence and showing the client 92

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that the mind will finish it. For example, say, “Mary had a little . . .” or “Don’t put all your eggs in one . . .” The client’s mind will automatically finish these statements. Help normalize this for the client. This is just what minds do. Similarly, the client cannot help that thoughts about pulling are going to show up in certain situations, such as in the bathroom. Thus, the question is not “How do we stop this process” but “How can we notice it and respond to it for what it is?” The “tree on the road” metaphor can help demonstrate this point: When our mind starts chugging along and doing what it does—​observing, judging, categorizing, creating rules, and on and on—​we have to realize that we have to make a choice. We can either treat our mind as if what it says is truth and follow along, OR we can realize that our mind just does what it does and behave in a way that is consistent with our values. Sometimes that will be consistent with what our mind is jabbering about, and sometimes it won’t be. It is sort of like the following two scenarios. In the first, you’re going to a really important meeting (your values), and the fastest way to get there is on this back road. As you drive down the road, you come to a point where a large tree has fallen across it. You would like to keep going, but the tree is in the way. You don’t have a saw or a way to tow it out of the way, so you must stop, and you can’t continue until the tree is out of the way. It is a real problem, and one you must solve. Often, when we feel an urge to pull our hair, our mind starts making up rules that it tells us to follow. It tells us that that we have to stop what we’re doing and start pulling, because we MUST get rid of the urge. But is this really the best approach? Are the urges to pull really like trees in the road? Can we really not behave in a way that is consistent with our values until the urges are removed? Consider a second scenario. You are driving down the same road but are waved down by a group of laughing teenagers who say, “You can’t keep going because a large tree has fallen over the road.” Now, the teenagers may be telling the truth or may simply be having some fun with an out-​of-​towner. Although you can’t see the tree for yourself, you have a choice: You can keep going with this warning in your head, or you can turn around as though there really is a tree up ahead. What if what our mind tells us about urges is like the teenagers’ warnings, but not the actual tree? Could you keep going in your valued direction, even in the presence of those urges? How do you treat your urges to pull hair—​as real 93

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trees that are on the road or as warnings? Remember, trees are really in the way; warnings are not the actual thing you are being warned about.

Rescuing Your Child/​Pet Sometimes altering the context in which we experience thoughts can help change their impact on us. This next exercise offers a distinction between diving into a cold choppy lake to save either a beach ball (an item of low importance) or a pet or a child (enormous importance). This exercise can be helpful with thoughts like, “I’ll start working on my pulling next week when I’m less busy” or “this urge is too huge to ignore”. Help the client see that the power of thoughts can easily vary based on how we treat them. After this exercise you might say to the client, “Are you treating that thought like you are going to get a child or a beach ball?” When things are really important to us, we often do not have the luxury of listening to our minds or being fused with our inner experiences. For example, imagine you are standing by a lake and see one of your beach balls floating in the middle of the water. It is a long swim and the water is cold and choppy, and you have to decide whether or not to swim out and get your beach ball. Immediately your mind starts telling you things. You will have thoughts that the lake is choppy, and it may be associated with apprehension about swimming out. You may think that the water is cold; you may start to shiver and have doubts about swimming out. You may have thoughts that you could drown, and you may ultimately decide that it’s better not to swim out. In all of these cases, we are fused with our thoughts. But what does defusion feel like? Let’s change it up. What if that object in the middle of the lake isn’t a beach ball, but rather your child who had strayed offshore or your pet who had swum too far out and is now struggling to stay above the water? Would you have the same thoughts about the cold, choppy water or about how you could drown? Would you feel anxious? Perhaps. However, would you treat those thoughts and emotions as if they were real barriers to getting into the water or would you just start swimming? I think most of us would just start swimming because we had to, and we would give those thoughts no more

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consideration or power than they deserve in that situation. That is what defusion feels like: operating from a point of liberation from the thoughts, emotions, and urges, even as they are still present.

Choice When it comes to pulling, clients often feel they do not have a choice in pulling. The urges are strong, and cognitions that sometimes lead to pulling seem accurate in the moment. Still, the client does have a choice. To make that choice clear, and to show where the control over pulling lies, the following exercise is useful. Stand in front of the client and ask them to use any words to get you to walk. The only rule is that the client cannot physically touch you. Regardless of what the client says, do not move. Clients usually start by saying, “Walk.” When you don’t move, they may say something like, “Pick up your right foot and place it in front of you.” When you still do not move, the client may try a number of other things like guilting or threatening you. Eventually, the client just sits there or says they can’t make you move. At this point, begin a discussion on the nature of thoughts, emotions, urges, or cravings, paying specific attention to the fact that they are not a physical entity and, as such, cannot exert physical force on an object. Then, revisit with the client how much control they think words, urges, cravings, or emotions actually have over behavior. It is then useful to point out that even though the urges, thoughts, or emotions make it feel like the client has no choice in whether to pull, ultimately, it is the choice of the client whether they pull. In any instance where the pulling is about to occur, the client should understand that they have a choice. Make an attempt to relate the exercise back to the client’s pulling experience. Exercise: Acting Without Reasons In this exercise, called “acting without reasons,” the client is shown that they can choose to stop pulling rather than trying to talk themselves into stopping. The function of this exercise is to help the client make choices without having to satisfy their mind that they are making the

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right one. It involves asking the client to think of reasons why they should not pull and then come up with counter-​reasons for pulling. If the client really works at it, they will be able to come up with just about as many reasons to pull as those not to pull. Use this information to help the client see that their mind will not let them work this problem out logically; not pulling is a matter of choice (a decision made without reasons). Case Vignette 6.2 illustrates this.

Case Vignette 6.2 Therapist: We are going to do a little exercise to help you see how useful your mind is at helping you decide whether you should pull or not. Tell me about the last time you really struggled with whether you should pull or not and then ended up giving in. Client: Last night is a good example. I was getting ready to go to sleep, I saw that there were a couple of odd hairs, and the urge to pull them just shot up. I thought that I had been doing really well with my pulling—​my hair is coming in—​but I really wanted to pull those hairs out. You know me: If I pull a couple, then I usually end up pulling a bunch. I knew that if I pulled, I would be mad at myself for giving in, but I knew that if I didn’t, then I would have this urge all night and might not sleep well. I really struggled with what I should do. Therapist: It sounds like it was hard for you to make a choice last night. Client: I ended up pulling for only 5 minutes. That is really good for me. Therapist: Good job keeping your pulling down. I want to talk about this struggle that you had over whether to pull or not. Let’s come up with five good reasons that you should not pull. Client: That’s easy: (1) I will look better; (2) I will have more time; (3) I will not have to feel so bad about myself; (4) My mom will be off my back; (5) Finally, I will be able to do things like swimming, sports, and dating without worrying about my bald spots. Therapist: Great job. Those are all very good reasons. Let’s come up with some reasons to pull. Client: Why would I want to do that? Therapist: I am not saying you are going to follow them. I just want to show you the limits of your mind. I bet we can make a pretty good argument to pull. It is a little silly, but let’s give it a try. 96

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Client: (1) If I pull, then I don’t have to deal with the urge for a little while; (2) I do actually enjoy the pulling sometimes; (3) It is a part of my life that I am unsure about giving up . . . That is all I can think of. Therapist: Make up some goofy ones, such as maybe a tweezers company will hire me to test their tweezers. Client: OK. Maybe pulling is actually good for your health and the doctors don’t know it. Therapist: Great. I bet we could come up with 100 more reasons for pulling and 100 against it, right? Maybe this is not a problem that we can figure out logically. You are a smart person and will be able to make a good argument for or against pulling. Have you ever watched politicians debate? They are generally pretty good at arguing both sides of an issue. You can do the same thing in your head. Therefore, pulling or not pulling may be a choice (an action done without reasons) rather than a decision (an action done for reasons).

Exercise: Playing with Your Urges in a Different Way The content of this exercise is similar to that of defusion exercises described in other ACT books. It is often helpful to let people interact with their private events (thoughts, feelings, and bodily sensations) in a different, goofy way. Clients often take their thoughts about hair pulling and urges very seriously and literally. Exercises like these, in which the client interacts with their thoughts and urges to pull in a different way, lessen how literally these thoughts are experienced. These exercises can be started by having the client touch their head or think about pulling to induce the urge to pull. Feel free to make up other ways that one can interact with urges to pull. Here are some examples: 1. Have the client describe their urges to pull as being either a cat or a dog. Have them describe the breed, age, size, color, activity level, etc. Get them to talk about what the cat or dog (urge) is like. Finally, ask if there is anything about this animal that they can’t take care of. Would they have this animal in their life if it needed a home? Would they adopt it? 97

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2. Ask them to describe the urge as if it were a television commercial. What would it be an advertisement for? What would be taking place? What voices would be in it? You can tell the client to think of the urges or self-​talk about pulling in this way when at home. 3. What would the urge be like as a person? What would they look like? How would they dress? How would they act? 4. The client can also imagine their urges to pull or thoughts about pulling as texts on their smartphone, an announcer at a baseball game, or a screaming child at a grocery store.

Exercise: Evaluation Versus Description This exercise focuses on helping the client experience their urges to pull and thoughts about pulling more as they actually are and less as what their mind tells them they are. In a factual way, urges are not dangerous things. No feeling is actually dangerous. It is the way we respond to feelings that can be dangerous. Pulling to get rid of the urge, avoiding social situations to prevent embarrassment, or avoiding relationships is what causes problems. People sometimes seek out the very same feelings that they work so hard to avoid or eliminate. For example, some people ride roller coasters but avoid a similar feeling of anxiety that comes along with meeting a new person. Strip away the context and cognitive evaluations of the feelings, and they are pretty much the same core sensations. You cannot stop the client from interpreting their urges, thoughts, and emotions about pulling, but if they can become more aware of the process that is taking place, they will be able to see these interpretations for what they are, and accepting their presence will be easier. Case Vignette 6.3 helps describe this topic.

Case Vignette 6.3 Therapist: We are going to do another sort of goofy exercise. When we usually describe something, we use its physical properties as well as our evaluations of it. For example, the physical properties of this pen are that it is blue, plastic, hard, skinny, smooth, etc. And my evaluations of it are that it is useful and the appropriate 98

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color for business, it was inexpensive, or perhaps my wife gave it to me, and it has emotional meaning. If every person on the planet disappeared and an alien found this pen in 1,000 years, the properties of blue, plastic, hard, skinny, and smooth would still exist, but the alien would not say it is appropriate or meaningful—​those are properties that are not in the object. Properties such as those are verbal—​they are not real. Let’s look at your urges to pull hair. What are the properties of your urges that nobody would argue with? Client: I can sense a tingle in the area where I pull from. I have tension throughout my body. It is uncomfortable. Therapist: Is being uncomfortable actually part of the urge? Isn’t that something that was added? Client: Yeah, I guess so. Therapist: Good. Now let’s look at some of the properties of the urge that are added; they are your evaluations of it. Client: It is bad, it is uncomfortable, it hurts sometimes, etc. Therapist: Great. Do you see the difference between the two? If I paid you a million dollars for every minute you felt the urge, it would no longer be bad or uncomfortable, but it would still be tingly and make your body tense. Even for one million dollars you could not change its properties. Keep this in mind next time you are struggling with this urge. There are parts of the urge that are real and parts of it that are added by your mind.

Exercise: The Pull of Your Mind As written earlier, clients often come into therapy with the belief that the therapist will be able to stop or lessen their urges to pull. The focus of ACT is to help the client function better in the presence of these feelings, while not trying to control them. This concept is important because the more the client thinks they should not have urges, thoughts, or emotions that lead to pulling, the more likely it is that they will end up in a struggle with these very phenomena. One nice way to help a client see this is through the “pull of your mind” exercise. This will help the client experience the fact that one thought will always pull another. Often what happens is that the opposite thought is pulled. Thus, the

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more the client struggles to weaken urges, the stronger they become. The exercise involves stating a thought that has to do with hair pulling and helping the client see how it pulls the thoughts in the other direction. First give the client the following instructions: I am going to say a couple statements that have to do with your hair pulling. I want you to see what your mind does with them. Most people say that they respond to the statements in some way. Close your eyes and tell me what your mind says after I say the following thoughts. There is no need to say more, just tell me what your mind says first. ■ ■ ■ ■ ■ ■

There is nothing wrong with pulling. There are no good qualities to pulling. Only people who are messed up pull hair. Stopping hair pulling is easy. You can control your urges to pull. You can’t control your urges to pull.

Say a number of bold statements and see how the client responds to them. It is likely that clients will say the opposite of the statement. For example, the statements there is nothing wrong with pulling and there are no good qualities to pulling are opposite statements, but neither is totally true. The client’s mind will find the opposite of these statements. Help the client see this. Finally, through discussion, help the client see that trying to talk themselves out of the thoughts they have while pulling will ultimately pull them into the struggle with their pulling, rather than take them out if it. The mind is too smart for this—​it will automatically pull in the opposite direction.

Exercise: Take Your Urges with You Have the client write their main inner experience that pushes them toward hair pulling on a small piece of paper. It might be the thought, “That hair will have a huge bulb.” We then ask the client to put their hand up and we then push the paper against the client’s raised hand. We push hard so the client starts to get a little tired. We ask, “Is this similar to how you treat this thought?”—​indicating the fight against the inner experience. Then we take the piece of paper and tell the client to put it in their pocket. We then ask, “Is the inner experience touching you in both situations?” We also ask, “Which one is taking more work?” We then suggest that not 100

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fighting against these inner experiences is a lot less work and the thought will be there either way. We suggest the client carry that thought around for a while, representing an openness to this emotion.

Exercise: Talking for the Client This exercise should only be done with clients who are less defensive and more willing to have some difficult emotions. This is a good exercise for a client who is doing well in therapy and on board with the ACT approach to TTM. It is a typical defusion exercise in which the client has the opportunity to see their thoughts, urges, emotions, and cravings to pull hair in a different way. Have the client get in a position where they are ready to start pulling. We usually have the client look in a mirror at the area that they pull from. Having the client hold one of their usual pulling tools can also help the exercise. Instead of having the client talk about their thoughts about hair pulling, you will do the thinking for them. Say aloud what you believe the client is thinking. Then, switch roles and have the client speak for you. This exercise can be described in the following way: We are going to do another exercise where you get to see your thoughts about pulling in a different way. I want you to get in a position where your thoughts about pulling would show up. In order to see them in a different way, I am going to talk for them. I am going to be your mind for a little bit. I am not making fun of you or picking on your thoughts. I just want you to be able to see them in a different light. If you start talking back to your mind, I will have to tell you it is not your turn. After doing this for a few minutes, let the client speak for you. Pretend you are about to start pulling (e.g., look in a mirror and hold a pair of tweezers). The thoughts verbalized by the client at this point are likely the very same thoughts they have themselves. Continue this exercise for another couple minutes. Once the exercise has been completed, discuss with the client their reactions to the practice. Although most clients report that this is a funny exercise, it is a very effective way of helping clients view their thoughts about pulling in a less literal way.

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Behavioral Commitment to Reduce Hair Pulling Work with the client to create another behavioral commitment to reduce hair pulling. (See Form III: Behavioral Commitment Form, which can be found near the end of Chapter 6 in the client workbook or in Appendix B of this therapist guide, and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.) Use the following points to develop the behavioral commitment. 1. Be specific. 2. Do something that gives the client a high chance of success. 3. Link the commitment to values. 4. The commitment should involve the continued use of HRT, trigger reduction strategies, and other ACT processes. 5. Make sure the client knows to adjust the commitment if needed.

Between-​Session Work As this chapter covers two sessions, you will be setting up these activities with the client both weeks. ✎ Instruct the client to engage in the “Being Present” exercise for 5 to 10 minutes every day until the next session. The client should continue to monitor hair-​pulling episodes over the ✎ course of the next week using Form I: TTM Self-​Monitoring Form, engage in the chosen competing response, and implement trigger reduction strategies The client should make a behavioral commitment to reduce hair ✎ pulling.

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CHAPTER 7

Session 8: Practicing Acceptance and Commitment Therapy (ACT)

Materials Needed ■ Form I: TTM Self-​Monitoring Form (available in both client workbook Session 8 and therapist guide Appendix B) Form III: Behavioral Commitment Form (available in both client ■ workbook Session 8 and therapist guide Appendix B) Form IV: Making Friends with Your Inner Experiences Form ■ (available in both client workbook Session 8 and therapist guide Appendix B) Items needed to evoke client’s urge to pull (individualized to client, ■ but could include mirrors, tweezers, etc.) Therapist Note All forms, graphs, and worksheets can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Session Outline ■ ■ ■ ■ ■

Conduct weekly assessment of progress Inquire about any reactions to material from previous session Review between-​session work Present the Embracing Your Urges exercise Discuss acceptance and defusion as learned skills that require practice

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Continue behavioral commitments ■ Assign between-​session work ■ Therapist Note Chapter 10 near the end of this therapist guide contains modifications for working with adolescents, organized by session. Refer to that chapter if you are working with this age group.

Completion of Assessment Measures As in every session, the client should return or complete an assessment to gauge progress. This progress (or lack of it) and the client’s reactions should be discussed. Help the client plot assessment data on the Weekly Graph of Progress, provided on page 81 of the client workbook.

Review of Previous Material Ask the client to share thoughts on and reactions to the topics discussed in Sessions 6 and 7.

Review Between-​Session Work Praise the client for engaging in the self-​monitoring process. Review and troubleshoot implementation of the habit reversal training (HRT) and trigger reduction strategies. Point out the importance of continued monitoring and use of pulling management strategies. Plot the self-​monitoring data on the Daily Graph of Progress (provided on the last page of each chapter in the workbook) to examine fluctuations in pulling. Discuss patterns and trends in the data and ask the client why certain trends in the pulling may have developed. Give the client the opportunity to acknowledge any reactions they may have had to pulling-​ related inner experiences. Review results of behavioral commitment exercises from last session.

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Embracing Your Urges Exercise At this point, the client should be aware that urges to pull and other inner experiences surrounding pulling are incredibly difficult to control, that attempts to control them are often more of a problem than the inner experiences themselves, and that inner experiences surrounding pulling present themselves as much more real and literal than they really are. Therefore, learning to see them for what they are and make room for (i.e., accept) the presence of these experiences, rather than trying to control them, might be a more functional way to address them. This session, and the session that follows, will give the client opportunities to work with this new way of looking at hair pulling. Behavior therapists and other therapists who work with anxiety disorders will be quite familiar with this type of work. We suggest using procedures from exposure therapy and doing so in a context where the client is encouraged to “make friends” with the urge to pull and to see these experiences for what they really are—​ just feelings, sensations, and words in their head. In this sense, the goal is not to reduce unpleasant experiences, though such a reduction might occur because of natural habituation and extinction processes. Rather, the “behavioral exercises” in this program involve learning to interact with pulling-​related inner experiences in a new way: one where the experiences are seen for what they are, and the client is more open to their presence. Some of this work has occurred in previous behavioral commitment exercises, but starting in this session, the exercises have a more purposeful function. In earlier behavioral commitment exercises, the client worked on decreasing their pulling while practicing connecting with values and engaging in defusion and acceptance. Going forward, we are going to turn up the heat during behavioral commitments and give the client more powerful opportunities to connect with their values while working on defusion and acceptance. The work of these sessions is much more like a difficult real-​life situation.

Conceptualizing Before the Exercises To help the client get the most out of these exercises, you will need to look at your client’s assessments and do a small amount of case

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conceptualization. You need to determine the pulling-​ related inner experiences that are most notable for your client. It might be a particular thought, a sensation in the pulling area that is there before pulling, a feeling caused by pulling, a strong interest in a certain hair or hair follicle, or the sensations from manipulating pulled hair. In all likelihood, it is a few of these at one time. Knowing the target inner experiences will help you structure the exercises to be most useful. The next step is to figure out which ACT skills the client needs to build. We want to link every exercise to the client’s values. You need to decide whether teaching defusion, acceptance, or likely both (before the exercise) is the best plan. Again, we want the client to practice experiencing their pulling-​related thoughts, urges, sensations, and emotions in a therapeutic way, as demonstrated in Case Vignette 7.1. We want some skill growth to occur as a result of these exercises.

Case Vignette 7.1 Therapist: Before we get rolling with an exercise for the day, I want to spend a minute reminding ourselves why we are working so hard to get your pulling under control. Tell me what things you are most excited about getting back in life. Client: I think the two biggest things are time and freedom. I put a few hours into pulling per day and I hold back in a lot of places because of my bald spots. Therapist: I hear you. Can you do me a favor and connect this hard work we do in session and between sessions to these goals? What we do today will not solve trichotillomania, but what we do today, added to the last few weeks, and the work you do over this next week, can make a real difference. Just like each board and nail in a home matters, each exercise and session matters. Client: Yes. I get it. I’ll put in a good effort. [Once you feel that the client is motivated to participate in the exercise, you can move into the rationale for the behavioral exercises.] Therapist: Up until you started working with me, you put quite a lot of effort into controlling your urges to pull hair, and, interestingly, 106

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that did not work out that well. There was a lot of time spent controlling the uncontrollable, and you never really stopped pulling. Maybe it is time we started doing the complete opposite of what you have been doing. Instead of working to control these feelings, like you had been doing, let’s practice making room for them. What do you do that brings on your desire to hair pull? Client: Mirrors, tweezers, and touching my hair. Therapist: OK, let’s use the items on that list and purposefully work with them. We are not taking them out to pull; we are taking them out to make friends with your urges to pull. Client: So, what do you want me to do? Therapist: If you are willing, we will work on getting your urge to pull to show up so that we can practice doing things other than pull in its presence. We’re going to use some of the things that trigger your urge and play with them a little. This is like playing Game 2 while the player in Game 1 taunts you and tries to get you to play their game. The rules for this exercise are as follows: Pick a specific behavior and do it for a specific amount of time, while being open to what shows up and noticing it for what it really is. I would like you to participate in the exercise until your time is up. The exercise has nothing to do with getting used to the urge or decreasing it. I just want you to become familiar with it and build a new relationship with it. Know it fully. Don’t run away from it. The longer you stay around something, the more you get to know it. Depending on what typically makes the client want to pull their hair, work with the client to pick a specific behavior or situation that will make them experience the urge. Examples could include looking in a mirror for 10 minutes, holding a tweezers for 10 minutes, or pulling out one hair to get the urge to show up. There should be an agreement to engage in the exercise for a specific amount of time. This exercise is different from exposure that is done with anxiety disorders in that there is no concern about the strength of the urge or thoughts about pulling. It does not matter how high or low the urge or thoughts are, or if they decrease throughout the session. The focus is on how open the client is to what is there. If the client notes that the urge is decreasing, ask, “Is that what we are about here?” The client needs to be reoriented to: ■ increasing acceptance of the urge,

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defusing the literal meaning of the urge, ■ remembering the values they are working toward, and ■ committing to behavior change and succeeding with it. ■ You are welcome to draw on previous exercises to reinforce the needed skills.

Responses to Use During the Exercises This exercise also provides wonderful opportunities for the therapist to strengthen the processes that have already been targeted: acceptance, defusion, and values. Again, the goal of these exercises is to help the client build a new relationship with their pulling-​related inner experiences. It is not about habituating to the inner experience. Therefore, you do not need to ask how high the urge is. You may, but it would be more of an assessment of the client’s situation. More important questions relate to how the client is treating the inner experience. Are they allowing it to be there, or are they fighting with it? Can they sense it is just a thought, or is it big and pushing them around? Finally, is the client connected to their values, or are they just doing this to please you? These processes are a little more difficult to detect if you are less familiar with ACT. But generally, if the client is unwilling to experience any part of the urge to pull hair, then acceptance may be targeted. If the client experiences the urge to pull as a real and dangerous thing, then more defusion processes can be targeted. Also, if the client lacks motivation or is not fully invested in the exposure, then a discussion of values can be useful. Following are examples of occurrence of one of these processes and possible responses to them.

Acceptance Avoidance can generally be detected when a client refuses or avoids a feeling, thought, or inner experience. This might occur in this exercise when a client is not willing to do a part of it or suggests doing something easier. It might even be in subtle actions the client does to lessen the 108

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exercise. Avoidance will also show if the client is doing small things in their head to try to regulate the inner experience, like telling themselves, “It is OK. I can pull later.” Ways to address avoidance in session include: ■ ■ ■ ■ ■ ■

Ask the client if they are playing Game 1 or Game 2. Ask the client to “open up” a little to the feeling they are pushing away. Ask, “Is this really a feeling you can’t have in your life?” Say, “Let’s try and open up to that feeling a little more.” Remind them to “not push the feeling away.” Ask them to “Treat this urge like a lost child. It just needs somewhere to be for a little while.”

Defusion The process of defusion needs to be addressed when the client appears to be pushed around by thoughts about pulling and pulling-​related inner experiences. You can generally detect that these events are being taken literally when the client appears fearful of them—​as though they are real things. The client might say something like, “But won’t that make it so bad that I end up pulling?” Fusion is generally addressed by helping the client see that thoughts, feelings, and bodily sensations are not real things to fight with. Ways to address fusion include: ■ Ask the client if the private event is real, like the table or some other real object in the room. Say, “Thank your mind for that thought” or “That is an inter■ esting one.” Use silly descriptions of the private events established earlier, such as ■ a lost animal, a pop-​up ad, a text, or a television commercial. You can say, “How long has that thought been around? How much ■ longer are you going to let it be in charge?” You could say, “Let’s just let that feeling be there for 2 minutes and ■ then we will come back and check on it.”

Values If the client is struggling to participate in the exercise, then it is usually a good idea to link the exercise to something that is important to the 109

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client. Exposing the client to pulling-​related inner experiences is not an end in itself, but is done in the service of something meaningful, like being with their family more or just having a full head of hair. Simply linking the exercise to these activities should increase motivation to participate in the exercise. Ways to address lack of motivation to participate include: ■ Ask the client why they are in therapy and what they have to gain from learning to function with their urges. Say, “This exercise might bring you one step closer to [insert client’s ■ valued activity].” Say, “Would you do this for [insert person they will have a stronger ■ relationship with]?” Remind them that each exercise is one step toward their values. ■ Politely ask, “Do you want your urges to choose or your values?” ■

Behavioral Commitment to Reduce Hair Pulling Work with the client to create another behavioral commitment to reduce hair pulling. (See Form III: Behavioral Commitment Form, which can be found near the end of Chapter 7 in the client workbook or in Appendix B of this therapist guide, and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.) Use the following points to develop the behavioral commitment. 1. Be specific. 2. Do something that gives the client a high chance of success. 3. Link the commitment to values. 4. The commitment should involve the continued use of HRT, trigger reduction strategies, and ACT. 5. Make sure the client knows to adjust the commitment if needed.

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Between-​Session Work ✎ The client should continue to monitor hair-​pulling episodes over the course of the next week using Form I: TTM Self-​Monitoring Form, and engage in the pulling management strategies. Ask the client to complete Form IV: Making Friends with Your ✎ Urges Form as a way to identify those situations where the urges and other private events surrounding pulling are likely to occur. This form can be found near the end of Chapter 7 in the client workbook or in Appendix B of this therapist guide, and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The client and therapist should agree to engage in a new behavioral ✎ commitment exercise to decrease pulling. During the Embracing Your Urges exercises, the client may have ✎ used various stimuli (e.g., tweezers, mirrors) to bring about urges to pull. However, the client’s trigger reduction strategies may have them reduce contact with those same stimuli. Work with the client to stop using these trigger reduction strategies, so the client starts to have greater opportunity to practice embracing the urges during the week.

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CHAPTER 8

Session 9: Practicing Acceptance and Commitment Therapy (ACT) and Review of Treatment

Materials Needed ■ Form I: TTM Self-​Monitoring Form (available in both client workbook Session 9 and therapist guide Appendix B) Form III: Behavioral Commitment Form (available in both client ■ workbook Session 9 and therapist guide Appendix B) Form IV: Making Friends with Your Inner Experiences Form ■ (available in both client workbook Session 9 and therapist guide Appendix B) Therapist Note All forms, graphs, and worksheets can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Session Outline ■ ■ ■ ■ ■ ■ ■

Conduct weekly assessment of progress Inquire about any reactions to material from previous session Review between-​session work Continue Embracing Your Urges exercises conducted last week Introduce relapse prevention Continue behavioral commitments Assign between-​session work

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Therapist Note Chapter 10 near the end of this therapist guide contains modifications for working with adolescents, organized by session. Refer to that chapter if you are working with this age group.

Completion of Assessment Measures As in every session, the client should return or complete an assessment to gauge progress. This progress (or lack of it) and the client’s reactions should be discussed. Help the client plot assessment data on the Weekly Graph of Progress, provided on page 81 of the client workbook.

Review of Previous Material Ask the client to share their thoughts on and reactions to the topics discussed in the previous session.

Review Between-​Session Work Praise the client for engaging in the self-​monitoring, habit reversal training (HRT), and trigger reduction strategies. Point out the importance of continued monitoring and use of these management activities. Plot the self-​monitoring data on the Daily Graph of Progress (provided on the last page of each chapter in the workbook) to examine fluctuations in pulling. Discuss patterns and trends in the data and give the client the opportunity to acknowledge any reactions they may have had to use of the HRT procedures and pulling-​related inner experiences. Address any difficulties the client had, and make any necessary modifications to the procedure. Review results of Embracing Your Urges exercises in Session 8. Review the client’s completed Form IV: Making Friends with Your Inner Experiences Form, and discuss their success with ACT processes of change.

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Continue with Embracing Your Urges Exercises Hopefully the client has found some value in doing these exercises and has practiced them between sessions. We are going to continue with them in this session. Again, there is no better way to learn ACT processes than to practice them in real-​life situations. Luckily, TTM is a disorder where we can easily create situations in which to practice. Remind the client that they are doing exercises to “create a new relationship with pulling-​related inner experiences.” We want to move from a situation where pulling-​related inner experiences are events that push the client to engage in actions that regulate experiences, to a situation where these inner experiences are just inner experiences the client notices and does not interact with. In other words, we want to get good at living even when those feelings are around. This can be described as follows: We are going to continue with the exercise we did in last session. In this exercise, you bring up the thoughts, feelings, urges, or sensations that typically lead you to pull your hair. While you are experiencing these inner experiences, you will get the chance to practice letting them be there. This work always reminds me of the visiting team shooting free throws at a basketball game. The home-​crowd fans behind the hoop start to make a lot of noise, maybe boo you, and wave things around. With this exercise, you are the person shooting the free throws and your inner experiences are the opposing team’s fans. They are trying to distract you, but your job is to not let them. You just need to do what you’ve been asked to do. First, the exercise should let the client practice while having the particular inner experience with which they most commonly struggle. This is a good opportunity to discuss with the client which inner experiences they want to practice with. Find the ones that lead them most into the pulling. This could be the thought, “I know there is a really good bulb up there,” or an urge to eat the end of a hair. You will want to design an exercise that brings up these inner experiences. Second, help the client connect with the value in doing this work. Find the thing that will make doing this somewhat difficult exercise worth it. Third, determine which processes of change the client should focus on while engaged in the behavioral exercise. For example, if the client is really pushed around

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by their inner experiences, then focus on defusion. If the client is more likely to struggle in letting the inner experience exist without reacting to it, then address acceptance. In all likelihood, focus on both processes will be needed, as defusion and acceptance are related constructs. Either way, lead into the behavioral exercise with some discussion of which process they should practice. It can be as simple as saying, “In this exercise I want you to treat your urges to pull like a bully on a playground.” You may also go back to the chapters on acceptance and defusion and reuse some of those examples. After these topics have been covered, you and the client can spend as much time as possible practicing having the pulling-​related inner experiences. This is a dynamic exercise. The client exposes themselves to situations that bring on their inner experiences, and you coach the client to see these experiences for what they are while allowing them to exist.

Relapse Prevention: Reviewing What Has Been Learned Ask the client to review the therapy and tell you what they have learned. Contact the following points. ■ Habit reversal is used to control pulling, and ACT procedures are used to step out of the struggle with urges and other private experiences. Trigger reduction strategies can make it less likely that the client’s ■ pulling will occur. Reducing a trigger is a way of making a commitment to pull less well before the client is caught up in the struggle to pull. Review the benefits of moving in the direction of values instead of ■ focusing energy on controlling a feeling. Urges, emotions, thoughts, and cravings cannot be controlled. It is ■ the attempt to control these inner experiences that is the problem, not the experiences themselves. Another option for trying to control pulling-​related inner experiences ■ is to make room for them in our lives, through acceptance. Habit reversal can help us allow the urge to be present and, in that way, can facilitate acceptance.

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■ Urges, emotions, thoughts, and cravings do not have to be treated as real things that force us to act a certain way. They are not things we have to fight with. The client works hard to make room for the urge and other inner ■ experiences as they gain control over pulling, because there is something important to them, not because they have to. These skills require consistent practice in our lives. ■

Behavioral Commitment to Reduce Hair Pulling Work with the client to create another behavioral commitment to reduce hair pulling. (See Form III: Behavioral Commitment Form, which can be found near the end of Chapter 8 in the client workbook or in Appendix B of this therapist guide, and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup. com.) Use the following points to develop the behavioral commitment. 1. Be specific. 2. Do something that gives the client a high chance of success. 3. Link the commitment to values. 4. The commitment should involve the continued use of HRT, trigger reduction strategies, and other ACT strategies. 5. Make sure the client knows to adjust the commitment if needed.

Between-​Session Work Ask the client to identify barriers to maintaining treatment gains. ✎ The client should continue to monitor hair-​pulling episodes using ✎ Form I: TTM Self-​Monitoring Form over the course of the next week. The client should engage in the chosen competing response, and im✎ plement trigger reduction strategies. Instruct the client to continue behavioral commitment exercises ✎ while using HRT procedures and practicing acceptance and defusion.

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CHAPTER 9

Session 10: Review and Relapse Prevention

There are no materials needed for this session.

Session Outline ■ ■ ■ ■ ■ ■

Conduct weekly assessment of progress Inquire about any reactions to material from previous session Review between-​session work Discuss continued monitoring and check-​ins Discuss relapse prevention techniques Celebrate accomplishments and completion of therapy

Therapist Note Chapter 10 near the end of this therapist guide contains modifications for working with adolescents, organized by session. Refer to that chapter if you are working with this age group.

Completion of Assessment Measures Today the client will complete their final weekly assessment. Using their previously completed assessments, point out the progress the client has made in treatment. Plot the latest data on the Weekly Graph of Progress, provided on page 81 of the client workbook.

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Review of Previous Material Ask the client to share their thoughts on and reactions to the topics discussed in the previous session. This is the client’s last chance to clarify concepts and ask any questions they may have.

Review Between-​Session Work Praise the client for engaging in the self-​monitoring and using habit reversal training (HRT) and trigger reduction strategies. Point out the importance of continued monitoring and use of the pulling management procedures. Plot the self-​monitoring data on the Daily Graph of Progress (provided on the last page of each chapter in the workbook) to examine fluctuations in pulling. Discuss patterns and trends in the data and give the client the opportunity to acknowledge any reactions they may have had to use of the HRT procedures and pulling-​related inner experiences. Review results of the Embracing Your Urges exercises in Session 9. Also review client successes in reducing pulling.

Discuss Continued Monitoring and Check-​ins Great benefit can come from self-​monitoring and checking in with someone. Accountability goes a long way. Tell the client that it is wise to keep these activities going even after therapy ends. We often suggest clients leave an appointment time in their calendar as a reminder to ask themselves, “How are you doing with your hair pulling?” or “Are you working on keeping it under control?” At the weekly appointment time, ask the client to pause and really think about where they need to put in more efforts. Relatedly, these are good times to think about which procedures from Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-​T) the client is letting slip. As we will cover later, the client can go back through the workbook and start practicing these procedures again.

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Review of Relapse Prevention Strategies Remind the client to continue using the skills learned in therapy, and discuss common pitfalls and methods for addressing them. There are two primary pitfalls. The first involves becoming less reliable in using HRT and trigger reduction strategies. This is relatively common in treatment as clients show improvement and become less motivated to do the hard work of managing the pulling. To deal with this pitfall, it is helpful to discuss the concept of lapse versus relapse and to discuss strategies for staying vigilant in doing HRT, trigger reduction strategies, and strategies for addressing cognitive fusion and the control agenda.

Lapse Versus Relapse Discuss with the client the possibility that there may be occasions when pulling starts to increase and they are spending less time working to control it. Frame this possibility as a lapse, rather than as a complete relapse. A lapse is a slip or partial loss of improvement. Lapses may occur when experiencing situations or may simply be due to lack of practice of the skills learned in treatment. If the client experiences a lapse, encourage them to look at it as an opportunity to reevaluate how they are responding to urges to pull and efforts to use HRT and trigger reduction procedures.

Vigilance in Using HRT and Trigger Reduction Strategies The client should be made aware of typical patterns in treatment compliance. As persons using HRT and trigger reduction strategies begin to have success, they typically become less compliant with the procedures. To counter this, it may be useful for the client to schedule daily practice sessions during which they practice the HRT procedures on simulated hair-​pulling episodes. It can also be helpful for the client to post reminders of their trigger reduction strategies in areas that are at high risk for triggering pulling. Similarly, it can be useful to encourage the client to look back over their workbook once per week and remind themselves of the work that was done, especially in high-​risk situations (e.g., life crises, stressful days).

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The second main pitfall involves falling back into Game 1. Falling back into Game 1 will result in more time fighting with urges, increased pulling, and less time pursuing the meaningful parts of life. It can be easy to fall back into old patterns of emotional control because they are so well supported in society. It was only in therapy where emotional control was not encouraged. Below, we suggest different ways of helping the client continue to play Game 2.

Increase in Cognitive Fusion Because the client is functioning in a daily context that supports cognitive fusion, they may find themselves once again reacting to pulling-​ related thoughts, urges, or emotions as if they were real events with physical characteristics. If the client notices this, establish a plan in which they remind themselves of the defusion exercises and practice them on a daily basis.

Returning to the Old Agenda The client may notice a return to an old agenda of attempting to control negative private experiences. An increase in pulling may be a signal that this is occurring. Should the client notice that this is occurring, they should call you and discuss possible ways to return to the agenda of acceptance and willingness.

Celebrating the Completion of Therapy In this phase, review with the client the progress made in therapy. Congratulate the client on their progress. Remind the client that these initial sessions should only be viewed as the start of therapy, and that they are encouraged to come back for additional sessions if the pulling begins to increase or they find themselves having difficulty allowing the private experiences to exist without having to respond/​react to them. Answer any questions about future issues or options for booster sessions, and terminate the session.

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CHAPTER 10

Modifications for Working with Adolescents With Julie M. Petersen, MS

Our research has shown that Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-​ T) can be successfully implemented with adolescents (aged 12 to 17) via in-​person therapy or over telehealth. When we do this work, we follow the same protocol as with adults, but many of the aspects of the treatment program are implemented differently or specific modifications are made. This chapter includes session-​by-​ session alterations and suggestions for implementing AEBT-​T with adolescents. As with adults, this psychotherapy needs to be tailored to the client. Developmental level and insight into their trichotillomania are likely the best guides when determining where and how to modify this protocol. When you follow the modifications in this chapter, you will see that we spend a bit more time building relationships with the client, as adolescents take a little more time to warm up and trust the therapist. Adolescents might not have struggled against their pulling as long as most adults so they may have lower motivation to change and may not be as aware of their struggle with urges to pull. The adolescent might be in a bit of a fight with the caregiver over the pulling, and this disagreement might be negatively affecting the adolescent’s interest in working on their pulling. We have redone many of the exercises to be more appropriate and memorable to adolescents. Finally, there are some newer elements to adolescent work, including the need to work on motivation issues with reinforcement programs.

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Modifications for Chapter 1 (Session 1) Client Motivation Clients with TTM often have low or ambivalent motivation for change because pulling is often enjoyable. When change is sought, it is often motivated by the desire to reduce or eliminate real or perceived social consequences stemming from the act or result of hair pulling. For some younger adolescents, those aversive social consequences have not been contacted in a meaningful way, and therefore they are just left in contact with the pleasure of pulling. Therefore, we highly suggest you assess for client and caregiver motivation to stop pulling. If the youth is highly motivated to stop pulling, then proceed with treatment. If the youth is mildly motivated to stop pulling, focus on some rapport building to increase comfort with therapy, and spend some extra time in the values section of this guide (Chapter 3) to hopefully build motivation for treatment. A reward schedule can also be powerful for working with slightly motivated youth. If developmentally appropriate, encourage the youth (and caregiver, if necessary and/​or wanted) to develop a system to reward the youth for resistance to pulling through using therapeutic skills (see Chapter 2). Youth can also be motivated by “streaks,” tracking how many hours/​days/​weeks in a row they can resist pulling. Brainstorm some ways the youth can track their “streak” and set goals for each week (e.g., a 7-​day streak of no pulling, a 3-​day streak of four hairs or less pulled). Some examples of streak-​tracking methods include using cellphone or computer apps, making tallies on a whiteboard in their room and/​or kitchen, or using artistic skills (e.g., beginning a large painting or drawing and adding one thing for every day where no pulling occurs). Each young person is unique, and some may love an idea that others dislike. The key is to encourage the youth to be creative and have fun. If the youth is not motivated for treatment but the caregiver is, consider talking with the caregiver about starting treatment after the child is showing some interest in working on their pulling. It may also be helpful to approach the unmotivated youth with curiosity and openness; inquire about the benefits they gain from pulling or what it brings to their daily life and/​or identity. For example, questions such as “What

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would your life look like without pulling? How does that compare to right now?” or “How is pulling your friend? How is it not your friend?”

Rapport Adolescents generally require a bit more time to warm up to a therapist. We suggest some ice breakers so that the client has some time to settle in and habituate to seeing you. Discussing the client’s favorite television shows, movies, video games, sports, or hobbies is a nice way to warm the child to participating. It may be especially helpful to ask the young person to show you examples of their art, music, or hobbies, if they are willing. Younger clients also generally enjoy hearing a little about your life so that you seem more like a “regular” person. The game “Would you rather” can provide a good opportunity to get to know each other—​be sure to answer the questions and take turns asking. Some options could include: Would you rather have a superpower or unlimited money? Would you rather speak every language or be able to read minds? Would you rather have blue toes or purple fingers? Finally, we also find that shorter sessions can make therapy less aversive. If all the work is done and the adolescent does not love being in session, then allow them to end early if you two covered everything you needed to cover. If the youth prefers, you can also reserve the last part of session to spend time discussing a favorite topic or playing a game.

Caregiver’s Role The caregiver’s role in TTM work is based on the client’s developmental and maturity level. We have had precocious 12-​year-​olds who are incredibly engaged in the work, and 16-​year-​olds who are simultaneously playing video games on their phones while seeing us. Simply based on developmental level, caregivers may be involved in the sessions anywhere from the first or last 5 to 10 minutes of the session to the entire session. In general, we have the caregiver join us for the first or last 5 to 10 minutes to either hear the caregiver’s thoughts/​concerns or have the client explain to the caregiver what we went over in session. If done at the end of the session, before bringing the caregiver back, it is especially 125

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helpful to have the client tell you what they learned in session first. This repetition is also a nice opportunity for us to see if the client is retaining the right information. Some clients who are less engaged in the sessions can benefit from the caregiver’s presence for much more of the session. This is especially true of Sessions 1 and 2, where the skills are concrete and do involve caregiver support. A large caveat to caregiver support has to do with the relationship between the client and the adult around pulling. We feel there is a relatively even split between caregivers and children who fight about pulling and caregivers who are experienced as supportive by the adolescents. In cases where the relationship is contentious, the conflict must be addressed first before enlisting the caregiver into the therapeutic process. This could be as simple as educating the caregiver on how TTM works (e.g., stopping is beyond the adolescent’s ability without therapy; wearing Band-​Aids or using fidget toys will not be enough). Education about basic parenting skills such as validating and empathy might be needed if most issues around TTM end up in a fight. Caregivers may also need education focused on the specific needs of the client who pulls as compared to their other children; we have observed that caregivers are sometimes reluctant to provide rewards or special attention because their other children might not get rewards in the same way (i.e., if a child is part of a reward system for working on pulling while other children are not). Reminding the caregiver that each child is unique in their needs and struggles can go a long way. In the cases where the relationship is quite strained, you might have to really educate the caregiver that they need to pause on the TTM parenting and let the client and therapist work together. We sometimes call this “retiring the pulling police.” With caregivers who are in a contentious relationship with their child, it is time for them to follow your lead. If they are not willing to pause, maybe another caregiver or family member will help with treatment, or family therapy might be more appropriate. The ultimate goal when working with caregivers is to encourage them to act as cheerleaders, not coaches. Assuming it is developmentally appropriate (i.e., the adolescent is old enough and sufficiently motivated), the caregiver ideally would be cheering on the client rather than telling

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them what to do. For example, optimally engaged caregivers may use encouraging words (e.g., great job using your skills!), be diligent about tracking rewards, ask how they can help rather than assuming (e.g., How can I help you make a plan to resist while watching a movie tonight?), and make time for the caregiver–​child relationship outside of pulling (e.g., outings where pulling is not discussed, special one-​on-​one time). Pulling can be very frustrating for caregivers, and they also may benefit from learning ACT concepts for dealing with their frustrations.

Attention-​Deficit/​Hyperactivity Disorder (ADHD) In our work in TTM and other habit behaviors, ADHD is the diagnosis that most often complicates treatment success. Regulating hair pulling requires high self-​management and delaying gratification, issues with which individuals diagnosed with ADHD struggle. If the youth is diagnosed with ADHD, work with the caregiver to ensure that ADHD is appropriately managed before starting work on TTM. If the client has well-​managed ADHD, then there is benefit to the caregiver being in the therapy room more regularly. Also, making sessions shorter and/​ or incorporating breaks (e.g., a quick game, doing jumping jacks or a yoga pose) can also increase on-​task time. It may also be helpful to break sessions down further and have a greater number of shorter sessions rather than trying to force the client to focus for longer than they are currently capable of. Clients should also be encouraged to take notes or use other accommodations they might have in school to help them remember and/​or engage with treatment (e.g., typing up concepts together on a shared document, writing down ideas as session progresses, drawing treatment concepts, taking extra or less time to execute skills).

Modifications for Chapter 2 (Session 2) Make Habit Reversal Training (HRT) More Engaging There is a growing body of research on the use of HRT with younger clients. We have used HRT and trigger reduction strategies on children as young as 6 years of age. It works well across the age and developmental

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spectrum because it is very behavioral-​and skills-​based. When working with younger children, we suggest prolonging all awareness training practices. Have the adolescent mimic their pulling warning signs many times, while explaining aloud what they are doing (e.g., “I rest my arm here, my hand lifts this way, I start to feel around for the right hair, these are the things I think”). Have the adolescent talk about what they are looking for in a hair and how they choose which one to pull. Go over this repeatedly. As the therapist, you should also mimic the client’s pulling and warning signs (let them know you will be doing this, and why you are doing so), and the client should practice catching you. Seeing someone else do it can increase their awareness of the warning signs and the pulling. This can be turned into a fun game. We usually tell the client that while we are talking together, we will try to sneak in warning signs, and it is the job of the client to catch them. You can also implement awareness training while playing games with the adolescent (e.g., drawing games, charades, video games, “Simon says”) or watching a show with them. We do this for about 5 minutes. It can also help to tell the client that this game continues for the rest of therapy: you will try and catch each other’s warning signs. If appropriate, the young person could even practice awareness training with others like their caregiver, friends, siblings, or even themselves while looking in a mirror.

Need for Caregiver to Stay on Teen’s Good Side Part of the traditional HRT procedure includes social support. Although often omitted when working with adults, it can be quite helpful when working with youth. Social support involves having someone close to the client (a) provide support (or rewards) for appropriate use of the competing response and (b) provide gentle reminders when the client is engaging in warning signs or pulling but not using their competing response. Although potentially very helpful and recommended for youth, there is a note of caution with social support. As already noted, most caregivers do not understand TTM. They see their adolescent pulling and may feel frustrated by it. That confusion and frustration can easily show up when

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parenting their teen. A contentious relationship around pulling may already be in place before therapy begins. If this is the situation, providing effective social support will be a difficult step. Even if the caregiver and the teen have a strong relationship, implementing social support takes diligence and planning. As discussed previously, work with the caregiver so they understand that maintaining a supportive relationship with the teen around pulling is their best chance for success. It may be beneficial to facilitate a conversation between the teen and their caregiver to brainstorm how the caregiver can best support them. Some teens also prefer writing a letter with their requests to their caregiver, as it might be easier to fully express themselves in writing (e.g., “When you see me stroking my hair, please get my attention with this code word/​by saying my name/​asking me to stop”). If the teen is easily frustrated with the caregiver pointing out warning signs, then maybe only shift to reinforcing competing responses. We have had older teens who prefer to just report to their caregivers how many competing responses they did and then let the caregiver provide the agreed-​upon reward. The key is to have a transparent system that works for the teen and caregiver.

Caregiver Use of Rewards A reward system can work well if implemented correctly with this age group. Initially, the youth should earn rewards for the appropriate use of the competing response. Rewards could be made available for correctly doing the competing response, implementing trigger reduction strategies, or going for periods of time without pulling. Most therapists already know how to set up a reward system, so we will be brief about it. The rewards need to be immediately delivered for the target action. These can be points or tokens that are exchanged for something larger if that works for the client. The rewards also need to be reinforcing for the client. We often use free or inexpensive things such as time with the caregiver, choosing the movie or show, picking the dinner, or extended screen time or curfew. Most importantly, the program needs to be consistent and dependable. Remember to consider the cultural and financial situation of the family as you work with them to brainstorm a

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reward system. If the youth does not want to include their caregiver in making rewards, discuss how they might be able to reward themselves privately (e.g., watching an extra episode of TV, buying a treat, doing a craft, spending extra time with their pet).

Modifications to Reducing Pulling Triggers Young people can be the experts on their pulling triggers, but it can take some effort to help the youth identify them—​so be sure to set aside a good amount of time in one or two sessions to allow for a full exploration of pulling triggers. Most teens are able to identify at least some areas or situations where they are more likely to pull. It helps to ask them about their typical day in order to get a full assessment. For example, ask the teen if they pull in school, specifically in their least favorite or most boring classes. Take the time to talk the teen through their usual day or schedule and assess whether pulling occurs (e.g., “I know you hate math class; do you ever pull during or on the way to math class?”). Once you are aware of their hobbies and activities, you can also ask about those (e.g., “When you play stressful video games, do you pull during or after?”). Once a wider array of triggers has been established, modifications can be more easily implemented (e.g., holding backpack straps with both hands while walking to class, using fists after every round of a video game even if the urge is not there). Caregivers can also be of assistance in determining triggers for the teen’s pulling. The caregiver can be asked about situations where more pulling is seen or emotional states when more pulling is likely. Additionally, some of the modifications can more easily be implemented by the caregiver. For example, if one bathroom triggers pulling, the caregiver might help the adolescent move into another bathroom in the house. They might help rearrange furniture or remove something that commonly increases pulling, such as a vanity mirror that the family uses. A final example we often end up implementing is that the caregiver takes over the tweezers. We understand the client may need to do some grooming, so the client can “check it out” for those moments and return it to the caregiver after its use.

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Modifications for Chapter 3 (Session 3) Be More Concrete This portion of treatment starts to focus on ACT principles and procedures. ACT aims to be experiential and metaphorical in order to break down the rule following and cognitive fusion that often underlies psychological disorders. However, this approach must be calibrated to meet the adolescent’s developmental level and be easily understandable. Thus, you should feel free to explain things more to adolescents and double check they are following the ideas you are trying to teach by asking them: “How do you understand this?”, “What does this mean to you?”, or “How does this apply to your hair pulling?” It also could be especially helpful to use personal and more light-​hearted examples from your own life to illustrate ACT concepts, as adolescents often value therapist self-​disclosure.

Pull Back on the Magnitude of the Value Values identification and connection stems from interacting with our environments and seeing what is important to us. Younger people potentially have been limited to the values of their immediate home, and they may not have developed strong values that will function as reinforcers out into the future. Adolescents are also in the process of identity development and typically engage in age-​appropriate exploration of the type of person they want to be. Thus, values and the importance of resisting pulling can be expected to shift regularly. Working on values with adolescents is therefore less about naming specific values and more about connecting to the general sense of purpose in their lives. To contact this feeling, it might be as simple as talking about people (family, friends, teachers, famous people) who the client looks up to and why. Another option is to encourage the adolescent to consider what actions they might want to bring into their life (e.g., What kind of person do you want to be when you grow up? How do you want to be different from or the same as your family members?). Values work

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also does not have to be conversation-​based, For example, ask the adolescent to draw their future, ideal self wearing a backpack. What does that backpack look like and what is inside? What does it mean to them? How does pulling relate, if at all? Depending on the developmental level of the client, it may even be appropriate to take another step back and engage in an activity the child loves, followed by asking them to identify how they know they are having fun or doing something important to them (e.g., What does it feel like? Where do you feel it? What is your mind saying right now?). Another option for doing values work with young people is to focus on shorter-​term goals early in therapy, particularly for those who might struggle to name values that are really reinforcing. For example, appearance could be something to initially work toward, but as therapy moves on, maybe larger, more meaningful values can be clarified and worked toward. Similarly, “testing out” values can be appropriate for someone who has not figured out what they strongly value. This is also why we have a birthday party exercise in addition to the tombstone: An 18th birthday makes more sense to a teen than a tombstone.

Adolescents Blocked from Some Consequences of TTM One thing we have run into when working with teens is that they can be blocked from some of the negative consequences of hair pulling because those consequences fall on their caregiver. Specifically, the finances and time needed to manage the consequences of pulling can be taken up by the caregiver. Caregivers are the ones who keep fake eyelash appointments for a child who pulls eyelashes and purchase expensive wigs and makeup to help cover the pulling. Finally, any care needed for the pulling is usually organized and paid for by the caregiver. We are not saying the caregivers should remove this care; rather, we want to highlight to the therapist, client, and caregiver that this form of motivation is largely landing on the caregiver, possibly resulting in the caregiver being more motivated than the client. This affects some of these motivational discussions in this session.

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If the younger client can truly not name any negative consequence of pulling, a discussion around the positive aspects of pulling may be helpful. If the client can identify the pleasurable aspects of pulling, they may also be able to identify other activities that bring similar reinforcement. Once these are identified, the young person can explore more engagement in these things (e.g., find similar reinforcers elsewhere) while trying to increase resistance to pulling. Activities that bring positive reinforcement to the young person’s life can also be a window into their values or sense of purpose.

Keeping Caregiver on Client’s Good Side Talk with the client and the caregiver, sometimes separately, about their relationship around hair pulling. If the client finds the caregiver to be a positive support, then the caregiver can be used to strengthen the treatment and the adolescent’s values exploration/​engagement. If the caregiver relationship around pulling is conflicted, not only do we lose the help in treatment, but sometimes the client will purposefully not follow the caregivers rules around pulling. You may coach the caregiver on the behaviors you want to see from them, and use of values-​based discussion can also be helpful. For example, “I know you feel frustrated with your daughter around the pulling. I need you to demonstrate support, and while she is in treatment with me, I want you to only compliment her successes.” You can also set aside time for the caregiver alone at the end of session to briefly assess what values they can channel while trying new ways of responding to their child’s pulling (e.g., remembering what kind of caregiver they want to be, connecting to important religious beliefs around family). It may also be effective to have the adolescent share what they have learned about values from session and to ask the caregiver about their own values. As the therapist, it may be possible to facilitate a brief, values-​oriented discussion on how both caregiver and adolescent can lean on their values to succeed in reducing and stopping pulling. It may also be fruitful to ask the caregiver and adolescent to have this discussion privately as a homework assignment, making sure to focus on values exclusively and not pulling.

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Modifications for Chapter 4 (Session 4) Adolescents Have Less Life Experience The section of Chapter 4 titled “Long-​Term Effects of Urge Control” is implemented a bit differently with adolescents. This part of treatment assumes the client has had numerous interactions with their urges to pull and what really happens as the client tries to regulate those urges through pulling or other methods. In contrast, adolescents have likely pulled for a shorter duration and have likely paid less attention to the emotional processes surrounding pulling. Because of this, you may have to simply teach the idea that urges can only be controlled in the short term, not in the long term. Point out that if the adolescent spends many years trying to control their urges, the urges will only get very large and influential. However, if possible, move beyond didactic instruction and try a more experiential approach to see if the adolescent can pick up on the concept independently. It may be helpful to have adolescents imagine their life when they turn 21, or another age in the future: What do they think will happen to the urges? Adolescents may also be more easily taught these concepts with other emotions (e.g., anxiety, annoyance at a sibling) and then discuss how pulling-​related internal experiences relate afterwards. For example, an adolescent might more easily understand that anxiety is very hard to control, and that attempts to push it away only make it more central and larger. Then, you can say, “Do you think urges to pull and anxiety work the same way?”

Caregivers Need to Learn About Emotional Acceptance Caregivers of youth with TTM may also have a difficult time understanding the acceptance-​based approach taken in ACT. A common assumption in Western societies is that we should be able to control or regulate internal experiences that are interfering. However, ACT has different assumptions. We need to help the caregiver appreciate that we are treating urges as very difficult to control (at the best they will lessen but will never go away). It can help to explain to adults that there are some internal experiences we can easily regulate, but events in our mind are 134

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different. Maybe compare it to an urge that someone with an addiction would deal with. If the caregiver can start to appreciate that the client is learning to “deal with” their urges to pull rather than get rid of them, then the caregiver can be of help as they talk with their teen. Caregivers may pick up on this concept naturally as the teen describes what they learned in session. It is important to check in with the caregiver at the end of session to confirm that it makes sense to them and if it is consistent with their own internal experiences.

Modifications for Chapter 5 (Session 5) Keep It Concrete Concepts like acceptance or willingness to have pulling-​related inner experiences might be more complicated with an adolescent. Although they will likely enjoy and follow along with many of the exercises that we have in these chapters, be clear about what you want them to do with the pulling-​related inner experiences. For example, you might say, “When you feel pressure on or in your pulling site, I want you to make fists and then just watch that impulse to pull. I want you to just watch it and do nothing with it. Don’t rub your head. Don’t tell yourself it will go away. Just wait it out. Act like you are OK that it is there. You are training your body to be OK with these types of feelings.”

Acceptance Exercises There are several more active ways to illustrate acceptance to a younger person. The finger trap exercise is a classic ACT exercise to teach the benefits of acceptance. It involves purchasing “finger traps”, which are multicolored woven tubes of paper. They are inexpensive. If you insert your fingers into each end of them and then try and pull apart, they tighten on your fingers. The only way to get them off without breaking them is to sort of push in while rotating your fingers. This is a fun example of acceptance. You can also have the client write “my urge” or draw their urge on a piece of paper. Take the paper, crumple it up, and try to toss it in the client’s lap. The client should be given the instructions of trying to keep the crumpled paper off their lap. If the client knocks 135

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the paper away, pick it up and try again to toss it on the client’s lap. Ultimately, the client should notice that attempts to keep the paper off their lap is much more work than simply allowing the paper to land on their lap and stay there. This provides a livelier example of acceptance.

Do the Opposite Another exercise that teens enjoy is a game where you do the opposite. Whatever you ask the client to do, the client should do the opposite. If you say stand, the client stays sitting. If you say draw a circle on the whiteboard, the client should draw a square (maybe not the opposite). The list can go on and be fun and silly. Then you can tell the client that they should play the same game with the pulling-​related inner experiences, even if the urge wants them to do something else. You can relate this to the idea of the young person becoming the “boss” of themselves and what they want to do while (i.e., even if ) internal experiences are challenging and telling them something else.

Rewards and Token Economy Earlier we suggested using rewards when the client implements a competing response. The caregiver can keep that program going, and if the reward program is useful, then they can also implement one for the pulling reduction. For example, if the adolescent commits to not pulling after 5 p.m., the caregiver and the teen can agree on some system to monitor the pulling, and the caregiver can provide the rewards. Remember, rewards are like values in that they bring delayed reinforcers into the present and make immediate less reinforcing actions more reinforcing.

Modifications for Chapter 6 (Sessions 6 and 7) Importance of Continued Reinforcer Program To the adolescent, stopping pulling is often less important than it is for an adult. Therefore, motivation enhancement procedures are often

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necessary and need to be a core part of treatment. Hopefully, you have already implemented some type of reward system or token economy to reward use of the competing response, general reductions in pulling, or both. Ask the client and the caregiver about the effectiveness of this program. In our experience, if a reinforcement program is not effective, it is because the program is not being effectively implemented, leading the client to give up on it. Work with the caregiver/​child dyad to create simple and implementable programs that positively affect behavior.

Caregivers and Defusion Defusion may be a new and odd concept for many caregivers and their adolescents. To ensure understanding, have the adolescent explain the defusion concept to their caregiver. Teach and encourage the caregiver to change their responses to the adolescent to promote defusion, even if in small ways. Double check that the caregiver understands the concept and that urges themselves are not the problem; emphasize, if necessary, that the goal of treatment is to reduce pulling behavior, not urges. Therefore, if adolescents are being expected to report decreases in wanting to pull or experiencing the urge, direct the caregiver to respond accordingly: “Thanks for telling me you had urges. What did you choose to do with them?”, “Is the urge to pull with us right now?”, or “Wow, it sounds like your urge is really loud right now! Don’t forget to use your HRT exercises.” It may also be helpful to present defusion to the caregiver using another emotion (e.g., anxiety, boredom) and relate it back to pulling. The caregiver does not need significant training in ACT and defusion, but some simple training can be helpful. For example, you may tell caregivers, “Urges to pull are sticky and hard to control. Therefore, we are working with your child to just notice urges, let them be, and continue on while the urge hangs out.”

Sensory Countdown Instead of some of the exercises presented in this chapter, adolescents seem to enjoy an exercise we call “Sensory Countdown.” We also like 137

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to present this exercise as a way to notice how our minds grab us from other activities. It is a particularly good exercise for kids who are impulsive and don’t enjoy the regular discussion in therapy. Remind the client to notice how hard it is to keep the mind out of the exercise. Tell them to notice when it jumps in and to just “say hi to the mind” and then come back to the exercise. After giving the client the rationale for the exercise, slowly ask the client to name five things they can see, then four things they can hear, then three things they can feel, then two things they can smell, and finally one thing they can taste. Be sure to ask them to describe each thing in detail to you, almost as if it were the first time they were experiencing the object or as if you are unable to experience the object yourself. If you move slowly enough through this exercise, the client will have moments where they are pulled away by their mind during the exercise. You can use this to discuss how this might be like their mind grabs them about pulling.

Attributing a Character to the Urge Younger clients often really benefit from attributing a character and/​or personality to their urge. Thus, it may be especially beneficial to spend more time in the “Playing with Your Urges in a Different Way” exercise. Encourage the adolescent to identify who or what the urge is (e.g., a character from a video game, book, or movie? A giant cloud? A monster?) and use that characterization throughout treatment. If the adolescent consents, discuss this new name for the urge with the caregiver and begin to use it regularly. Adolescents may also enjoy engaging in creative representations of the urge, such as drawing, painting, imagining, or writing a story.

Modifications for Chapter 7 (Session 8) Exposure Exercises Are Fun for Younger Clients In general, this phase of treatment goes smoothly with adolescents. They generally enjoy this work because it is active. Adolescents are the experts on the urge, but they may need some help brainstorming how to bring the urge up for the practice. Suggest active and engaging ideas to make the 138

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practice more appealing such as running fingers through their hair with the goal of making a ridiculous hairstyle, making silly faces in a mirror, looking at their hairs up close with a magnifying glass, or trying on filters via their phones or photo booth software (as long as hairs are still visible). Encourage silly and/​or light-​hearted engagement, as appropriate, and do the exercise with them; for example, if the adolescent is running their fingers through their hair, then you do the same with your own hair. Adolescents usually take a bit more coaching and guidance. You need to be clearer on exactly what you want them to do, for how long, and in what way. You will need to coach through the proper use of acceptance and defusion exercises. For example, instead of waiting for them to tell you about how they are pushing away certain inner experiences, you can just step in and coach them to use acceptance. Adolescents may also become more motivated when offered agency in the exposure (e.g., “How long would you like to do this for?”).

Adolescents and Values Sometimes it is useful to come back to concepts covered earlier. You may find benefit in going over values (or defusion or acceptance) a third or fourth time. When addressing values with adolescents you might need to find topics that are more similar to goals. For example, to increase motivation through this exercise you might focus on appearance or an exciting haircut the person will get. If going for larger goals, you might find examples of other individuals they would like to exemplify and how this exercise will bring them closer to that person (e.g., being able to resist pulling may bring the client closer to an admired video game streamer who can play games for hours at a time without having to stop to pull). You might ask or remind the client about someone they look up to and how that person has handled difficult things. You could also say something like, “How cool would it be if you didn’t have to deal with this issue on your 21st birthday?” During the exercise you can also encourage the young person to connect to the type of person they want to be in response to the urge. For example, an adolescent who highlights kindness or compassion as important values or elements of their personality may respond well to encouragement of applying the kindness to their urge (e.g., treating it like a lost animal in need of a home). 139

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Acceptance Exercise For exposures emphasizing acceptance, relate opening up to the urge to taking a big jump. Acceptance and willingness of their urge is similar—​ you are jumping (i.e., open to it) or you are standing; there is no halfway. Illustrate this by taking small jumps (maybe even off some nearby furniture to lighten the mood of a reluctant adolescent). The jumping metaphor can also be connected to many experiences adolescents may relate to, like getting into a cold pool. Encourage the adolescent to “take this jump” with you and open up to their urge.

Defusion Exercise To facilitate engagement in the exposure, ask the young person to imagine their urge (and any other feelings) like weather. Introduce them to this concept by asking them to connect some different feelings to types of weather (e.g., sunny for when they are amused, raining for the pulling-​related inner experiences, thunder for annoyance, snow for peacefulness). Encourage the adolescent to invite the urge in and act as the weather person. In this exercise, encourage them to be as silly and/​ or engaged as they’d like (e.g., using voices, standing up and pointing at an imaginary weather map). When they first invite the urge up, maybe it will be very stormy. However, as time passes, maybe they will grow more willing to get soaked in the rain—​or the storm will pass. Be sure to encourage the adolescent to identify all emotions that are coming and going throughout.

Modifications for Chapter 8 (Session 9) Embracing Your Urges for Adolescents Another option for these exercises would be to encourage the adolescent to engage in an enjoyable activity that typically brings up the urge. For example, ask the adolescent to bring in homework, the book they are currently reading, a small game (e.g., their hand-​held gaming system or a phone with some game apps), or ideas for a TV show to watch. Join

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them in the activity in a way that might bring up the urge—​this may be different across clients (e.g., reading quietly, playing a competitive round of games, having them work on homework while intentionally touching their hair).

Values and Embracing the Urge Transparently and intentionally connect the exercise and chosen activity to what is meaningful for the adolescent. During the activities, be sure to bring attention back to the urge and/​or the meaning behind the combined exercises (e.g., ask the teen to repeat why this is important, ask them how they are connecting to their best self ). Adolescents may also benefit from practicing a quick three-​step “reset”: Breathe, open up, and do what matters. Before bringing up the urge, walk through these steps with the adolescent. The first step would be deep breathing, however you prefer to teach it, although we usually use “balloon breathing”: Imagine there is a balloon in your stomach and take deep breaths in while imagining you are filling it and then deflating it. Second, encourage them to “open up” to their urge by imagining it as their chosen character and giving it the OK to be there. Lastly, “do what matters”—​have the adolescent consider all their choices and select what will bring them closer to the type of person they want to be.

Acceptance and Embracing the Urge Young people may struggle with tracking and/​ or describing when they are feeling open or willing to experience pulling-​related inner experiences. One way to help teens better understand this process is to stand together by the light switch in the room and instruct the adolescent to turn off the lights when they have dropped the struggle and are open to their pulling-​related inner experiences. If they find themselves struggling with these experiences again, they turn the lights back on. This exercise provides an active way of tracking the pulling-​related internal experiences and keeps the adolescent attuned to them, while possibly enjoying the amusing nature of flipping lights on and off in the room.

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Defusion and Embracing the Urge During the exercise, teach the adolescent to “thank their mind.” This is a popular and common ACT exercise, and we find adolescents relate to it well, especially when you encourage them to modify their tone of voice. Ask the adolescent what their urge is saying and how the teen wants to respond. For some young people, they may want to tap into that element of kindness and respond gently. Others might want to connect to a value of power or strength and be sassier. Let the adolescent explore different ways of saying thank you to whatever the urge might be telling them (e.g., different languages, tone of voices, volumes). Keep the adolescent engaged in the exposure by asking them to narrate what the urge wants/​is saying and how they want to respond.

Modifications for Chapter 9 (Session 10) Caregivers Assist in Keeping Things Going As we have noted a few times, working on trichotillomania is not likely to be the teen’s number-​one priority. Therefore, caregivers can assist in setting up a trichotillomania review moment each week. During these reviews, the caregiver can check in on how pulling is going, review the topics to work on, and continue any reward systems or a token economy. If a weekly check-​in is unappealing to an adolescent, facilitate a discussion about how caregivers can be most supportive over time. Caregivers should also be encouraged to monitor their own frustration with pulling and to choose how they want to support their adolescent based on their values. It may also be beneficial for adolescents and caregivers to schedule regular private time (e.g., going for walks, cooking together, watching a show) that does not directly involve discussing or monitoring pulling. Because TTM can lead to conflict within families, these private moments without pulling-​related talk can build a foundation of trust and possibly reduce conflict.

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Self-​Compassion Adolescence is typically a tumultuous period, and it can be challenging to navigate changing emotions, external events, and relationships in addition to pulling. Adolescents may benefit from learning to apply self-​ compassion in responses to any lapses in pulling or other difficulties in their lives. A common self-​compassion exercise is to consider what an adolescent might say to a friend in the same situation. Have the teen pick a specific friend (or family member, pet, other loved one) and consider how the client has responded to the friend in the past when they were having a hard time. Ask the adolescent to write down some of the responses in their phone or journal to reference when/​if things become challenging. Adolescents may also benefit from imagining older or younger versions of themselves and choosing how to respond with these individuals in mind. To prepare the adolescent to use this technique, ask them to think back to a time when they were younger and made a mistake. Ask them to describe how other people responded to them—​was it helpful or unhelpful? How would they want their younger self to be treated if they make a mistake? Connect this exercise back to pulling and how they might treat their inner, younger self if they relapse. This exercise can also be utilized as a closed-​eye, guided visualization, if preferred.

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Appendix A Assessment Measures

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Milwaukee Inventory for Subtypes of Trichotillomania—​Adult Version (MIST-​A) Please choose a number which best represents how the question fits your hair-​pulling behavior. 1. I pull my hair when I am concentrating on another activity. _​_​_​_​_​_​_​_​ 2. I pull my hair when I am thinking about something unrelated to hair pulling. _​_​_​_​_​_​_​_​ 3. I am in an almost “trance-​like” state when I pull my hair. _​_​_​_​_​_​_​_​ 4. I have thoughts about wanting to pull my hair before I actually pull. _​_​_​_​_​_​_​_​ 5. I use tweezers or some other device other than my fingers to pull my hair. _​_​_​_​_​_​_​_​ 6. I pull my hair while I am looking in the mirror. _​_​_​_​_​_​_​_​ 7. I am usually not aware of pulling my hair during a pulling episode. _​_​_​_​_​_​_​_​ 8. I pull my hair when I am anxious or upset. _​_​_​_​_​_​_​_​ 9. I intentionally start pulling my hair. _​_​_​_​_​_​_​_​ 10. I pull my hair when I am experiencing a negative emotion, such as stress, anger, frustration, or sadness. _​_​_​_​_​_​_​_​ 11. I have a “strange” sensation just before I pull my hair. _​_​_​_​_​_​_​_​ 12. I don’t notice that I have pulled my hair until after it’s happened. _​_​_​_​_​_​_​_​ 13. I pull my hair because of something that has happened to me during the day. _​_​_​_​_​_​_​_​ 14. I pull my hair to get rid of an unpleasant urge, feeling, or thought. _​_​_​_​_​_​_​_​ 15. I pull my hair to control how I feel. _​_​_​_​_​_​_​_​

MIST-​A Scoring Template The MIST-​A contains two distinct scales. Scale 1 is referred to as the Focused Pulling Scale and comprises items 4 to 6, 8 to 11, and 13 to 15, while the Automatic Pulling Scale comprises items 1 to 3, 7, and 12. Scoring is relatively straightforward: Simply add the client’s scores for each item on these respective scales to yield a total scale score. Higher scores indicate increasingly focused and/​or automatic pulling, respectively. Flessner et al. (2008b) reported means and standard deviations for the focused (M =​45.4, SD =​16.2) and automatic (M =​25.7, SD =​9.04) scales based on data obtained from an internet sample of participants reporting symptoms of TTM (e.g., chronic hair pulling).

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Milwaukee Inventory for Styles of Trichotillomania—​Child Version (MIST-​C) People pull their hair for a lot of different reasons. Please choose a number between 0 and 9 that best fits how each question fits your pulling. You would put a “0” in the space provided if the question is not true of any of your pulling, and you would put a “9” in the space provided if the question is true of all of your pulling. Most kids fit between “0” and “9.” Numbers closer to “9” mean that the question describes more of your hair pulling, while numbers closer to “0” mean that the question describes less of your hair pulling. Please use the scale below to help you answer each question. 0-​-​-​-​-​-​-​-​-​-​1-​-​-​-​-​-​-​-​-​-​2-​-​-​-​-​-​-​-​-​3-​-​-​-​-​-​-​-​-​4-​-​-​-​-​-​-​-​-​5-​-​-​-​-​-​-​-​-​-​6-​-​-​-​-​-​-​-​-​-​7-​-​-​-​-​-​-​-​-​-​8-​-​-​-​-​-​-​-​-​-​9 Not true    True for about True for for any of my pulling    half of my pulling all of my hair pulling

1. I experience a strong urge or feeling before I pull my hair. 2. I think about pulling my hair before I actually pull. 3. I use tweezers or some other tool (not my fingers) to pull my hair. 4. I pull my hair to feel better or get some relief. 5. I pull my hair while I am looking in the mirror. 6. After I pull my hair, the urge to pull goes away or gets “better” for at least a little bit. 7. I usually do not know that I have pulled my hair. 8. I pull my hair when I am anxious or upset. 9. I pull my hair when I am stressed, angry, frustrated, or sad. 10. It is hard for me to stop pulling my hair. 11. I like the feeling of pulling my hair. 12. I have a “strange” feeling just before I pull my hair. 13. I don’t know that I have pulled my hair until after it has happened. 14. I pull my hair because of something that has happened to me during the day. 15. I pull my hair to control how I feel. 16. Pulling my hairs relaxes me. 17. I feel bad before I pull, but I feel worse after I pull. 18. The feeling I get after pulling makes me want to pull more. 19. When I am at school or work, I can’t wait to get home and pull. 20. Pulling gets rid of my bad feelings. 21. Pulling makes me feel good (at least for a little bit) 22. The bad feelings I have about pulling make me pull more. 23. I feel better after pulling my hair than I did before I pulled. 24. I don’t know I have pulled my hair until my parent(s) tell me. 25. I feel like I am in a “trance” when I pull my hair.

________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________ ________. ________ ________ ________ ________ 147

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MIST-​C Scoring Template The MIST-​C contains two distinct scales. Scale 1 is referred to as the “focused” pulling scale and comprises all items except numbers 7, 13, 24, and 25, which make up the “automatic” pulling scale. Simply add the client’s scores for each item on these respective scales to yield a total scale score. Higher scores indicate increasingly “focused” and/​or “automatic” pulling, respectively. Flessner et al. (2007) reported means and standard deviations for the “focused” (M =​95.9, SD =​35.5) and “automatic” (M =​13.3, SD =​8.7) scales based upon data obtained from an internet sample of participants reporting symptoms of TTM (e.g., chronic hair pulling).

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Acceptance and Action Questionnaire for Trichotillomania (AAQ-​TTM) Below you will find a list of statements. Please rate how true each statement is for you by circling a number next to it. Use the scale below to make your choice. 1

2

3

4

5

6

7

never true

very seldom true

seldom true

sometimes true

frequently true

almost always true

always true



_​_​_​_​_​_​_​_​1. It’s OK if experience the urge to pull my hair. _​_​_​_​_​_​_​_​ 2. My urges to hair pull make it difficult for me to live a life that I would value. _​_​_​_​_​_​_​_​3. I’m afraid of my urges to hair pull. _​_​_​_​_​_​_​_​4. I worry about not being able to control my urges to hair pull. _​_​_​_​_​_​_​_​5. My urges to hair pull prevent me from having a fulfilling life. _​_​_​_​_​_​_​_​ 6. I am in control of my pulling. _​_​_​_​_​_​_​_​ 7. Urges to pull cause problems in my life. _​_​_​_​_​_​_​_​8. It seems like most people are handling their lives better than I am. _​_​_​_​_​_​_​_​9. Urges to pull get in the way of my success.

AAQ-​TTM Scoring Template The AAQ-​TTM (Houghton et al., 2014) has a maximum score of 63 and a minimum score of 7. Higher scores indicate greater defusion, acceptance, and behavioral commitment, and less cognitive fusion, emotional avoidance, and behavioral inaction (e.g., higher scores are good; this is different than in the previous version of this book). Before scoring, reverse items 2, 3, 4, 5, 7, 8, 9 and then sum the scores. The mean scores for the AAQ-​TTM in a clinical sample were 40 for adults and 42 for adolescents.

149

150

Pulling Triggers Assessment Form (PTAF) General Instructions

The PTAF should be completed in Session 1 of Acceptance and Commitment Therapy (ACT) Enhanced Behavior Therapy for Trichotillomania (AEBT-​T). The PTAF should be completed by the therapist in conjunction with the client.

Specific Administration Instructions 1. In the “Pulling Site” column of the PTAF, the therapist writes down a recognizable description of all bodily sites from which the client pulls. The order in which sites are written is not important. 2. Before completing the PTAF, the therapist should deliver the following instructions to the client (italicized text represents what the therapist should read to the client): We are going to spend some time trying to determine when your pulling is more likely to happen. We’re going to go through each bodily site from which you pull. 3. For each pulling site, the therapist will ask the following questions: I’m going to first ask you about your [describe specific pulling site]. I’m going to ask you about settings in which you may pull, tools you may use to help you pull, and whether other people are around when you pull. Please say “yes” if [pulling site] is more likely to occur at this time or in this situation or around a particular person. I’ll follow these questions up with how those around you when you pull may react, and I’m going to ask about any visual or tactile sensations you may have while you pull or after you pull you hair. 4. Ask the client if pulling from a particular region is more likely to happen in each setting, whether a particular tool is used to pull from that area, and whether others are present when they pull from each identified pulling site. After determining the settings most likely to occasion pulling, go back and ask more questions to obtain a detailed description of what is happening in each setting that is making pulling more likely. Ask about reactions clients may receive from others in those settings, whether pulling allows them to escape from aversive tasks or experiences, and what kind of sensory experiences they have either during the act of pulling or after they have pulled the hair and are engaging in post-​pulling behaviors.

150

Bedroom

Pulling Site Settings

Watching Reading TV or playing video games

Bathroom

Other

Other

Tweezers

Tools Used Needles, Mirrors, safety reflective pins, sharp objects objects

Other

Others present when pulling

Social Presence

Feeling on your fingers; visual stimulation from looking at the pulled hair, etc.

Sensory stimulation

 15

152

If the description is sufficiently different from what has already been checked, write down a description of the antecedent in one of the “Other” boxes, and check the corresponding box. Ask for as much detail about each situation as you can, and take notes in the corresponding box. Continue with this process until the client has exhausted all antecedents for the pulling currently being discussed.

152

 153

Appendix B Client Forms, Graphs, and Worksheets

The forms, graphs, and worksheets in this appendix can also be found in the client workbook and can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Forms Form I: TTM Self-​Monitoring Form Form II: Monitoring Your Urge Form Form III: Behavioral Commitment Form Form IV: Making Friends with Your Inner Experiences Form

Graphs Daily Graph of Progress Weekly Graph of Progress

Worksheets Worksheet 2.1: Pulling Signals Worksheet 2.2: Trigger Reduction Strategies Worksheet 3.1: Living the Life You Really Want Worksheet 3.2: Tombstone/​Birthday Party Toast Worksheet 4.1: Paper in the Shoe Exercise

153

154

Form I: TTM Self-​Monitoring Form Instructions: Please record the amount of time (in minutes) you’ve spent pulling today. If instructed in the session, please record any other information in the space provided. Day

Day 1 (Day of Session)

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

154

Minutes Pulling

Description of Pulling Situation

Feelings, Thoughts, or Urges Before Pulling

Feelings, Thoughts, or Urges After Pulling

 15

Form II: Monitoring Your Urge Form Instructions: For each day, describe two or three times when you had a significant urge to pull your hair. Please describe what you did with the urge (pulled to get rid of it, tried to stop it, tried to distract yourself from it, tried to relax it away, etc.). Day 1

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Day 2

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Day 3

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Day 4

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Day 5

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

155

156

Day 6

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Day 7

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

156

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Form III: Behavioral Commitment Form What I am committing to do this week:

Be specific by writing out exactly what you will do, when, and for how long, so that if someone watched you, they would know if you met this commitment or not. ■ Remember, this is about building patterns one small step at a time. Pick a small goal that you can realistically achieve. ■

This commitment is important to me because (link to value):

While I work on my commitment I will practice (name psychological skill):

Practical, external barriers that might get in the way and how I will address them:

Consider barriers external to you that might make it hard to meet this commitment (stress, poor sleep). How can you address/​prepare for these ahead of time? ■ If you fail in one instance, remember to start working on it right away. Don’t quit. ■

I will do the following ahead of time to help meet my commitment:

Consider reminders you can set (on your phone, sticky notes, etc.). ■ Consider ways to make it easier or to get support for your commitment (have what you need set up ahead of time, let supportive friends/​family know what you are committing to, etc.). ■

157

158

Form IV: Making Friends with Your Inner Experiences Form Instructions: Please complete this form after you experience the urge to pull hair. This form need not be completed after every urge. The form only needs to be completed a couple times. Please bring the form to the following session. Day

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

158

Describe the situation

Describe your thoughts

Describe your feelings

Describe your urge or other bodily sensations during this situation

How did you manage these experiences in this situation?

 159

Daily Graph of Progress

Measure of Progress

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

159

160 k

k ee

W

ee

W

k

k ee

W

ee

W

k

k

ee

W

ee

W

k

ee

W

k

k

9

8

7

6

5

4

3

2

1

16

15

14

13

12

11

10

k

ee

W

ee

W

ee

W

k

k

ee

W

ee

W

k

k

ee

W

ee

W

k

k

ee

W

ee

W

Measure of Progress

160

Weekly Graph of Progress

 16

Worksheet 2.1: Pulling Signals My Pulling Signals  

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

 

2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

 

3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​____________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

161

162

Worksheet 2.2: Trigger Reduction Strategies Date Developed: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​Date Implemented: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Location of Pulling: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ List trigger reduction strategies for this pulling site

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



4. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Location of Pulling: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ List trigger reduction strategies for this pulling site

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



4. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Location of Pulling: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ List trigger reduction strategies for this pulling site

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



4. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Location of Pulling: _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ List trigger reduction strategies for this pulling site

1. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



2. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



3. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​



4. _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​___________________​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

162

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Worksheet 3.1: Living the Life You Really Want Instructions: This exercise aims to help you connect with areas of life that are really important to you and that might motivate you to work on controlling your hair pulling. Decreasing or stopping pulling will take a lot of work, and finding motivators can make that work more worthwhile. 1. Rename any of these areas if they do not fit you. This is your workbook, so you may adjust it. 2. Write what you care about in each area. Define your value. 3. Rate how important each area is to you. You can use a number (1 to 10) or simply rate them as low, medium, and high. Mostly, we just want you to connect with how important each area is to you. 4. Ponder how pulling and your fight against your urges to pull has moved you away from each value. 5. Choose a couple of areas (two or three) that you want to focus on improving and that can motivate you to keep working on your pulling. Remember, values are not meant to “guilt” you; they are meant to inspire.

Define Your Values 1. Marriage, couples, intimate relations _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ 2. Family relations _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​

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3. Friendships and social relations _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ 4. Career and employment _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ 5. Education, personal growth and development _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ 6. Recreation and leisure _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ 7. Spirituality _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​

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8. Citizenship _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ 9. Health and physical well-​being _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ 10. Others _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_______​_​

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Worksheet 3.2: Tombstone/​Birthday Party Toast Instructions: On the following lines, please write what you want written about you on your tombstone or what you would want said about you at a toast for your birthday party. What do you want people centuries from now to know about you? What do you stand for? What is important about you? _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​

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Worksheet 4.1: Paper in the Shoe Exercise Instructions: In the space provided below, write down a private event that you are trying to control by pulling your hair. Write down this thought here (or on a separate piece of paper), tear it out of the workbook, fold it in half three times, and place it in your shoe, underneath your foot. Keep it there for the course of the week. Your therapist will explain this exercise to you in more detail at your next session.

My Private Event _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_________​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​__________​

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Appendix C Caregiver Handouts

In the randomized controlled trial of ACT for adolescents with trichotillomania that we completed over telehealth (Petersen et al., 2022; Twohig et al., 2021), we gave the caregivers handouts that matched the sessions the therapists were conducting. Even though we offered to meet with the caregivers for the last 10 minutes of each session, sometimes they were not available, the adolescent was more developmentally mature and did not want the caregiver there, or it was simply hard for a caregiver to remember; thus, we thought these handouts were a helpful way to make sure the caregiver knew what we were working on. They also remind the caregiver how they can be helpful for the following week. You may choose to copy these and give them to the caregivers. These handouts can be photocopied from this appendix and can also be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

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Caregiver Handout for Session 1 What Is Trichotillomania? Trichotillomania (TTM) is a condition where individuals repeatedly pull out their own hair, leading to noticeable hair loss. People with TTM often experience anxiety and/​or depression symptoms in addition to their hair-​pulling behavior and urges to pull.

How Prevalent Is TTM? It is more common than you might think. Estimates range from 0.6% to 3.4% of adults. It most commonly begins around 10 to 13 years of age.

Automatic Versus Focused Hair Pulling Most people with TTM engage in two different types of pulling behavior. We call these automatic and focused. Both will be addressed in this program. It will be helpful for you to familiarize yourself with these terms. At this time, your child likely will not be able to tell the difference between automatic and focused pulling. That’s OK.

Automatic Pulling This is pulling that happens outside of your child’s awareness. This often occurs when people are engaged in an activity such as watching TV, reading, or daydreaming. Treatment will involve exercises to help your child become more aware in the moments.

Focused Pulling This is pulling that happens when your child is aware of what they are doing. Usually, focused pulling is done in order to reduce some type of urge, tension, emotion, or anxiety. Treatment will involve using exercises to stop pulling and learning to make space for these sensations and experiences.

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Why Does My Child Have TTM? Research is not at a point where we can answer that question. Both biological and environmental factors likely play into the problem. Regardless of the cause, though, we know that psychological treatment (like this program) can have a meaningful impact on trichotillomania.

How Can I Best Help My Child Succeed in Treatment? Between-​Session Work What people do between sessions can make or break treatment. Some form of between-​session work will be given after each session. Do what you can to set the stage for your child to engage in this work. This might include reminders, encouragement, or rewards.

Daily Check-​in Daily tracking is essential to monitor progress and help us know what is working or not working. Please do your best to complete this short check-​in each day.

Stay Positive Treatment can be hard—​for your child and for you. Remember that change takes time and that it won’t always go perfectly. Look at mistakes as learning opportunities, and keep moving forward.

Your Role Focus on being more of a supporting player on your child’s team and less their coach. You are there to help and support in whatever way that you both decide on and that you think fits best for them. Ask how you can be their best team player. Ask for permission to remind them about homework. Ask how they would like for you to handle times when you catch them pulling. Your support can make a huge difference, but only if they are willing to have it.

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Caregiver Handout for Session 2 Habit Reversal Training Purpose: To develop control of the act of pulling (not the urges to pull).

Awareness Training Purpose: (1) To recognize times or places where pulling is more likely to happen, such as in the car, before bedtime, etc. (2) To learn to recognize when pulling is about to happen or is already happening, such as noticing pressure or tension sensations or noticing playing with hair.

Competing Response Training Purpose: To have a go-​to tool to prevent pulling from happening when your child has an urge to pull or to stop pulling if your child has already started pulling. We will just use the word “exercise” to describe the competing response.

How to Do the Exercise Simply do the action decided on by your child and therapist (it is usually very simple, such as making fists, or putting hands to sides) for 1 full minute.

When to Do the Exercise Every time that your child has an urge to pull or notices that they have started pulling—​every single time. When the exercise is over, if they experience another urge, they should do the exercise again. Our goal is to make this a habit that is used any time that your child has an urge to pull or catches themselves pulling. This takes lots and lots of practice

and patience, but with time and persistence it will become natural and automatic.

TTM Trigger Reduction Purpose: Simply put, this is setting the stage to make pulling more difficult. Examples of trigger reduction: ■ Remove from the home hand-​ held mirrors, tweezers, or other tools used to pull (or placing them in your possession to request with your permission). Wear gloves or mittens OR hold an object (ball, ■ stuffed animal, etc.) when doing things where pulling is likely to happen, such as watching TV, reading, or lying in bed. Set a timer to limit time spent in bathroom (or ■ other pulling location). Set a timer that must be reset every 10 minutes ■ when watching TV to help with awareness of automatic pulling. Remove bright lights or reduce lighting near ■ mirrors where pulling happens. These should be simple, easy to implement, and consistently used but shouldn’t take over your child’s life. They should not be used to try to stop urges or thoughts related to pulling from happening (we will learn that this is counterproductive in the long run). The urges to pull are OK. We are working on stopping the actual act of pulling. Be creative and treat these as experiments. Try them for a few days; keep those that are helpful and discard those that aren’t.

Between-​Session Work Use exercises. Every single time! Begin using trigger reduction plan.

How You Can Help Ask your child how you can best help them to remember to use their exercise and the trigger reduction. ■ Stay positive and praise or reward your child when they do their exercise. ■ Don’t punish your child for not doing it. ■

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Caregiver Handout for Session 3

Values

Between-​Session Work

Why Is This Worth Doing?

■ Pay attention to hair-​ pulling episodes and reactions to the urges to pull (what thoughts, emotions, sensations come up?)

Values work helps your child to consider reasons for putting in all of this work. It is about more than just growing their hair out.

Living the Life Your Child Really Wants We spent time talking through areas of life that are important to your child and would motivate them to work on controlling their pulling. Motivators vary for each child. The key is to focus on things that are truly important for your child. When the child has to choose between giving in to an urge to pull or allowing it to be there and moving toward values, we hope the child chooses moving toward values. The opportunity to engage in values-​based choices over controlling urges will occur many times throughout the day. We hope your child gets more skilled at following values over controlling urges.

Just take note of them. We are just working on getting to know them right now. If your child wants to talk to you about their urges—​great! If not—​also great! Your child may prefer to discuss it with their therapist. ■ Continue to think about what fighting urges has cost. How will learning to deal with urges help? Keep the big picture in mind. This is more than just stopping pulling. It is about your child getting their life back. Your child may or may not want to talk to you about these things. Either way is completely fine. Your job is to be there for your child and offer support. ■ Use those exercises! Your child should use them every single time they have an urge to pull or notice that they have started pulling. We are building a habit, and this takes persistence. ■ Trigger reduction strategies Keep implementing and modifying these as necessary. Keep what works; modify or get rid of things that don’t.

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Caregiver Handout for Session 4

Urges Aren’t the Problem—​Control Is the Problem Your child likely does many things to try and control their urges to pull. These can include actually pulling, avoiding situations that make them want to pull, avoiding stress, wearing gloves, etc. It is not that these things are wrong or bad; in fact, they are probably helpful sometimes, especially in the short term. But when the main goal becomes getting rid of urges, we are fighting a losing battle that carries long-​term costs. Fighting the urges is usually our natural reaction, but it is counterproductive. It actually makes them worse! In the next session, we will discuss an alternative strategy to this control strategy. We call it willingness.

Between-​Session Work Therapy Exercises ■ Are you doing your best to support your child in doing their exercises? If they are willing to let you help them, it can be helpful for you to remind them periodically and praise or reward them when they successfully do the exercise.

Use of Competing Response ■ Make sure your child makes fists for a minute every time they want to pull, are about to pull, or are pulling.

Trigger Reduction Strategies ■ Continue using trigger reduction strategies. The goal of this work is to reduce pulling opportunities and make pulling a little more difficult. Please help your child implement these strategies.

Behavioral Commitments ■ Your child has made a commitment to limit pulling. Work with them to help meet that weekly goal. Remember to stay positive and reinforce success ■ rather than punish mistakes. Progress can be slow. Do your best to stay posi■ tive and encouraging during this process. In our experience there are usually easy days and difficult days. Think “big picture”!

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Caregiver Handout for Session 5

Urges Aren’t the Problem—​Control Is the Problem Let’s review this from last week: ■ Your child does many things to try and control urges to pull. It is not that these things are wrong or bad; in ■ fact, they are probably helpful sometimes, especially in the short term. But when the main goal becomes getting rid of urges, we are fighting a losing battle that carries long-​term costs. Fighting the urges is usually our natural reaction, ■ but it is counterproductive. It actually makes them worse!

Willingness Instead of trying to control urges, what if we tried something different? What if we practiced getting to know these urges and making space for them? We call this willingness. What if instead of fighting and trying to control this “urge monster,” we learned to make space for it and stopped letting it tell us what to do? This does NOT mean giving in to the urge and letting it run our lives. In fact, it is the opposite—​ it is noticing the urge for what it is (simply a thought, a sensation, etc.) and realizing that it does not have any real power to tell us how to live our life.

Between-​Session Work Keep using those exercises! These make for great opportunities to practice willingness. Keep using your TTM trigger reduction strategies and the competing response!

How You Can Help ■ Remember that urges are not something to be frightened of; instead, they are something that your child can learn to make space for and get better at having. Urges are not the enemy; pulling is—​and that is something that we have control of. Stay positive and praise or reward your child when they practice willingness. ■ Help your child complete their behavioral commitments. ■

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Caregiver Handout for Sessions 6 and 7

Description Versus Evaluation Our minds are wonderful tools that help us solve all kinds of problems. However, they can also cause problems for us. Let’s look at a simple example of how our mind works. If I ask you to describe the properties of an object, like this page for example (whether it is printed on paper or displayed on a screen), I am sure you could do it. You could describe the shape of each letter, the color of the box surrounding this text, and the sounds that the letters represent to form words. You could do this in a way that any person you described it to would agree. For instance, no one would argue with this description: “This text box consists of four sides.” At another level, though, your mind does more than just describe; it also evaluates. These evaluations are based on your personal history, memories, personality, etc. People will evaluate the same thing in very different ways. Let’s look at this text box again. How does your mind evaluate it? Is it good, bad, ugly, beautiful, poorly designed, etc.? When I notice the evaluation my mind gives of this text box, it says, “This text box is simple and pleasing to look at.” I would bet that your evaluation is a little different, and so too would another person’s evaluation.

So, What Does This Have to Do with Hair Pulling and Urges? Well, your child’s mind does the same thing. It both describes and evaluates their thoughts, emotions, and urges related to pulling. We are trying to get better at noticing the urges for what they are—​ simple bodily sensations (such as tension, itching, or pressure) and nothing more. However, like all of us, your child’s mind does not stop at the description. It also evaluates these experiences and tells a story about them. Perhaps the bodily sensations are “bad,” or “scary,” or “too much.” We are working to notice these evaluations for what they are—​stories that your child’s mind tells. They may seem very real, but with work we can practice noticing them for the bodily sensations and nothing more.

Between-​Session Work Exercises—​work to build a habit. ■ Trigger reduction—​keep it up! ■

How You Can Help When talking to your child about urges, try not to buy into the stories that they (and you) have about them. They aren’t “good” or “bad,” they just are. Look for descriptions of the urges and use those.

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Caregiver Handout for Sessions 8 and 9

“Embracing Your Urges” Exercise We want your child to spend some time intentionally inviting urges to show up and to practice “making friends” with them.

How to Do the Exercise The child will: 1. Set a timer for an agreed-​upon amount of time. A successful exercise is measured by this time, not how easy or hard it is. 2. Sit in front of a mirror and look at any hairs the child might have an urge to pull. 3. If no urges show up, the child should try touching, rubbing, or playing with their hair. 4. When an urge shows up, the child should use their hand exercise to keep from pulling. 5. The child should practice having an open, willing stance toward the urge. Let it come and sit on their lap without pushing it away. Instead of fighting it, be curious about it. 6. Notice the urge and practice describing any thoughts, emotions, or bodily sensations that come with it. 7. Notice any evaluations or stories that their mind tells about the urge or the exercise, such as “urges are bad,” “this is too hard to handle,” or “I am probably doing this wrong.”

How to Measure Success If your child does the exercise for the agreed-​upon amount of time, it is considered a success. It does not matter whether urges showed up or whether they were big or small. Remember, progress may not be fast. That’s OK; it takes time to develop habits and build skills. Think of this exercise as going to the gym. You wouldn’t expect to be able to lift a lot on your first day. But over time, muscles grow, and you can lift more.

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Caregiver Handout for Session 10

Relapse Prevention

Recommendations

Two big things to look out for:

■ Keep using exercises and trigger reduction. Even if your child feels confident, do not let these basic skills slip. Continue to track pulling behavior. This will ■ depend on your child’s situation and needs. Simply tracking behavior can have a great impact. Continue rewarding success. Rewards can be big ■ or small. A simple “good work” can mean a lot to some kids. Others may respond to working toward a larger goal such as a toy that can be earned for not pulling for a certain number of days. Relax. Kids have a tendency to have good days or ■ weeks followed by less-​good days or weeks. Urges are likely to come and go without warning. This is normal. Stressing out about it will likely just make your child anxious and less willing to talk to you about it.

1. Letting the pulling return; may be due to: a. Not using competing response b. Not using trigger reduction 2. Trying to control urges again; may be due to: a. Not practicing willingness

Lapse Versus Relapse There may be times when your child starts pulling more and is spending less time and effort working to stop pulling. It is important to remember that these “lapses” are common and normal. Treat these times as opportunities to re-​ evaluate and begin again when your child is ready. Lapses are to be expected and are OK, but we want to stop them from become a full relapse where your child is no longer making progress and has stopped working to improve.

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