Trichotillomania : An ACT-Enhanced Behavior Therapy Approach Workbook 9780199714551, 9780195336054

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Trichotillomania

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

Trichotillomania AN ACT-ENHANCED BEHAVIOR THERAPY APPROACH

W o r k b o o k Douglas W. Woods • Michael P. Twohig

1 2008

1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright © 2008 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press 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, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. ISBN 978-0-19-533605-4

9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper

About TreatmentsThatWork ™

One of the most difficult problems confronting patients with various disorders and diseases is finding the best help available. Everyone is aware of friends or family who have sought treatment from a seemingly reputable practitioner, only to find out later from another doctor that the original diagnosis was wrong or the treatments recommended were inappropriate or perhaps even harmful. Most patients, or family members, address this problem by reading everything they can about their symptoms, seeking out information on the Internet, or aggressively “asking around” to tap knowledge from friends and acquaintances. Governments and health care policymakers are also aware that people in need don’t always get the best treatments, something they refer to as “variability in health care practices.” Now health care systems around the world are attempting to correct this variability by introducing “evidence-based practice.” This simply means that it is in everyone’s interest that patients get the most up-to-date and effective care for a particular problem. Health care policymakers have also recognized that it is very useful to give consumers of health care as much information as possible so they can make intelligent decisions in a collaborative effort to improve health and mental health. This series, TreatmentsThat Work™, is designed to accomplish just that. Only the latest and most effective interventions for particular problems are described, in user-friendly language. To be included in this series, each treatment program must pass the highest standards of evidence available, as determined by a scientific advisory board. Thus, when individuals suffering from these problems or their family members seek out an expert clinician who is familiar with these interventions and decides that they are appropriate, they will have confidence that they are receiving the best care available. Of course, only one’s health care professional can decide on the right mix of treatments. This workbook describes a treatment designed for older adolescents and adults who suffer from trichotillomania (TTM), a disorder in

which individuals repetitively pull their hair to the point that it negatively affects not only their physical appearance but also the quality of their lives. If you have been diagnosed with TTM, this 10-week program can help you stop your unconscious hair pulling and teach you ways of dealing with the pulling you are aware of. You will learn about the concept of acceptance and how you can live with your pulling-related thoughts, feelings, and urges without acting on them or fighting against them. The main goal of this program is to teach you how to respond to your thoughts about pulling less literally so that they don’t control you. Throughout treatment you will work with your therapist to become aware of and recognize your pulling and the associated warning signals. Self-monitoring forms and weekly assessments, as well as metaphors, exercises, and home assignments reinforce the skills you learn in sessions. Use this workbook with confidence, knowing that, along with visits to a qualified mental health professional, this book will help you overcome your TTM and improve your well-being. David H. Barlow, Editor-in-Chief TreatmentsThatWork™ Boston, Massachusetts

vi

Contents

Chapter 1

Session 1: Introduction to the Program 1

Chapter 2

Session 2: Habit Reversal Training and Stimulus Control Procedures 9

Chapter 3

Session 3: Valuing 19

Chapter 4

Session 4: Does Control Work?

Chapter 5

Session 5: Acceptance 33

Chapter 6

Sessions 6 & 7: Defusion from the Literal Meaning of Language: You Are Not Your Urges 43

Chapter 7

Session 8: Practicing Acceptance and Commitment Therapy (ACT ) 55

Chapter 8

Session 9: Practicing ACT and Review of Treatment 63

Chapter 9

Session 10: The End of Treatment 71

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Weekly Graph of Progress 75 Appendix of Assessment Measures 77 About the Authors 81

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Session 1: Introduction to the Program

Chapter 1

Goals ■

To learn about trichotillomania

■

To learn about this program and what you can expect

■

To learn about habit reversal training (HRT ) and stimulus control

■

To begin self-monitoring

Weekly Assessment At the start of every session, your therapist will ask you to complete a weekly assessment. Examples of effective measures include the Milwaukee Inventory of Subtypes of Trichotillomania Scale–Adult (MIST-A), the Acceptance and Action Questionnaire (AAQ ), and the Acceptance and Action Questionnaire for Trichotillomania (AAQ-4TTM), all of which can be found in the appendix at the back of this workbook. Your therapist will work with you to determine which measures are best. You will use the information garnered from these assessments to graph your progress on a weekly basis throughout the course of this program. You may use the weekly graph provided at the end of this workbook and the daily graphs found at the end of each chapter to track your progress through therapy.

What Is Trichotillomania? Trichotillomania, or TTM, is chronic hair pulling resulting in noticeable hair loss. Individuals usually feel an increasing sense of tension immediately prior to pulling out the hair or when attempting

1

to resist pulling and feel a sense of gratification when pulling hair. Individuals typically experience significant distress or impairment in important areas of their life due to their struggles with the urges to pull and the hair pulling itself. The places people most commonly pull hair from are as follows: ■

Scalp

■

Eyebrows

■

Eyelashes

■

Beards

■

Pubic area

Prevalence

Research estimates are limited; however, it is speculated that somewhere between 10% and 15% of young adults pull hair, but only 2% to 3% experience noticeable loss and significant distress from pulling. Thus, hair pulling may occur on a continuum, ranging from benign hair pulling to more severe pulling that results in noticeable hair loss and distress. Gender Differences

Many more adult women present for trichotillomania treatment than men. This difference may only account for the number of people seeking help rather than actual differences in rates of trichotillomania. For example, in children, the gender distribution may be closer to equal, but a greater number of adult women seek treatment. Associated Problems

People with TTM often experience anxiety and depression, and may engage in other habitual behaviors such as skin picking, nail biting, or thumb and finger sucking. Nonetheless, probably the most notable way that trichotillomania affects people is in their relationships, jobs, and general quality of life.

2

Age of Onset

The mean age of onset is approximately 13 years. Hair pulling is sometimes preceded by a stressful life event or a change in environmental conditions, but in most cases there is no clear reason for its beginning. Patterns of Hair Pulling

Sometimes touching or stroking of the hairs occurs before pulling. Hair pulling is usually done by wrapping strands around the index finger when hair is long or by grasping shorter hair by the thumb and index finger. Others may use tweezers to help them pull. After hair is pulled, it may be discarded or used for post-pulling rituals. Many people report rubbing pulled hair between their index finger and thumb. Others chew or bite on the pulled hair. Genetic and Biological Factors

There is an increased probability of hair pulling, along with other psychiatric disorders, in first-degree relatives of individuals diagnosed with trichotillomania. The most common associated diagnoses found in first-degree relatives are major depression, anxiety disorder, and substance abuse. This sometimes raises the question of whether trichotillomania is a neurological or biological issue or an environmental problem. Research is not at a point where there is an answer to that question. Likely, both factors play into this problem. However, there has been considerable research showing that psychological interventions alone (without medication) are sufficient for the successful treatment of trichotillomania. Thus, it appears that psychological treatments for trichotillomania are robust enough to address the neurological, biological, and psychological components of this disorder. Automatic and Focused Hair Pulling

Automatic hair pulling occurs when you pull outside of awareness, while absorbed in an activity that requires your attention. Often you

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don’t know you are pulling until you are well into an episode or have already finished. About 75% of pulling falls into this category. Focused pulling describes pulling under awareness and with a strong urge to engage in pulling. Individuals who report focused pulling typically also report reductions in anxiety or tension after pulling. This type of pulling is likely done to control private experiences such as urges, sensations, thoughts, or emotions.

Overview of Treatment As just discussed, hair pulling can be either focused or automatic, and in many cases, people with TTM have both styles. Although the difference between these two types is important because it leads us to develop more effective treatments, the truth is that it may be difficult for you to distinguish whether a pulling episode is focused or automatic. For that reason, you and your therapist won’t spend too much time categorizing your episodes. You’ll simply do the treatments that were developed for each type of pulling. In Session 2, you will start doing the treatments that were designed to help you stop pulling. These techniques will take care of most of your automatic pulling. Focused pulling is specifically targeted in Sessions 3–8. During those 6 weeks, you will begin to look at your thoughts, feelings, emotions, and urges to pull a little differently. During this time, you will continue to work on decreasing your automatic pulling, as well as begin to look at some of the thoughts, feelings, and other bodily sensations (e.g., a tingling sensation on your scalp) that come before pulling. During weeks 9 and 10, you’ll review what you have learned and discuss ways you can maintain the progress you’ve made. You will be asked to do work during your sessions, as well as outside your sessions at home on your own time. Although some of this work may seem silly, full participation in treatment will give you the best chance of achieving the outcome you are looking for. Homework forms and worksheets are included in the workbook.

4

Expectations for Treatment The first part of therapy focuses on helping you get your hair pulling under control. As you work on stopping your pulling, you will find that your urges to pull will go up and down. The second part of therapy (Sessions 3–10) will address this area more specifically. Because you may view your pulling as being the same thing as your urges to pull, this therapy can be demanding and at times even confusing. This is normal and to be expected.

Introduction to Habit Reversal Therapy and Stimulus Control Procedures Habit reversal training, or HRT, is a technique useful for stopping the act of pulling. HRT will help you with the pulling by making you more aware of it and giving you a way to stop it. A second technique you will learn in treatment is called stimulus control. The purpose of stimulus control is to find things that make pulling more difficult for you to do. When behavior becomes more difficult it happens less. The goal of stimulus control is to come up with relatively simple strategies in your life that you can do to make your pulling more effortful. Work with your therapist to identify different situations that make pulling more likely. In Session 2, you and your therapist will select various interventions you can use in these situations that will make pulling more difficult.

Self-Monitoring Throughout the course of treatment, you will be asked to monitor your pulling. You will use the TTM Self-Monitoring Form provided at the end of the chapter to record any pulling you do during the day. Before you go to bed each night, use the form to record how much time you spent pulling your hair that day, describe the situations in which your pulling occurred, and describe the common thoughts, emotions, and urges that you had before and after each pulling episode.

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You will also keep track of your urges to pull. Use the Monitoring Your Urge Form, also provided at the end of the chapter, to note three times each day when you had an urge to pull your hair. For each of these urges, please write down what you did to deal with the urge, if you did anything. This may involve pulling, or it may not. Be sure to bring both completed forms to your next session.

Homework

✎ Begin monitoring your hair pulling on a daily basis using the TTM Self-Monitoring Form.

✎ Begin monitoring your urges to pull using the Monitoring Your Urge Form.

6

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

MINUTES PULLING

DESCRIPTION OF

FEELINGS, THOUGHTS, OR

FEELINGS, THOUGHTS, OR

PULLING SITUATION

URGES BEFORE PULLING

URGES AFTER PULLING

7

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

Day 1

Day 5

1.

1.

2.

2.

3.

3.

Day 2

Day 6

1.

1.

2.

2.

3.

3.

Day 3 1.

1.

2.

2.

3.

3.

Day 4 1. 2. 3.

8

Day 7

Session 2: Habit Reversal Training and Stimulus Control Procedures

Chapter 2

Goals ■

To participate in exercises that will help you recognize your pulling and your warning signs for pulling

■

To choose a competing response—something you can do instead of pulling

■

To discuss ways of making pulling difficult in certain situations where you are most likely to pull

Weekly Assessment At the start of the session, you will complete your weekly assessment and discuss it with your therapist. Be sure to plot your progress on the graph provided at the end of this workbook.

Homework Review After completing your weekly assessment, your therapist will review your homework assignments from the previous week. Come to the session with your homework completed and be prepared to discuss your reactions to the assignment(s). Plot the data from your daily self-reports on the graph provided at the end of this chapter.

Habit Reversal Training Today you will begin using HRT, which will help you stop pulling. HRT is implemented in two parts: awareness training and competing response training. 9

Awareness Training Today you are going to participate in awareness training exercises that will help you realize when you are pulling. Awareness training involves describing the pulling, describing the sensations and behaviors that come before the pulling (“warning signs,” or “signals”), pointing out therapist-simulated pulling, and acknowledging your own real or simulated pulling. Describing the Pulling

Your therapist will ask you to give a detailed description of what your pulling looks like. Please describe what your body does before you pull, while you’re pulling, and after you pull. Consider the following questions to help with this discussion.

10

■

Where does your hand usually come from as it goes to the area you pull from?

■

Do you search for hairs before pulling?

■

Do you stroke your hair before pulling?

■

Do you isolate a hair before you pull?

■

How are your fingers positioned before you pull?

■

When you pull, is the pull one quick motion, or do you tug until the hair comes out?

■

Do you use tweezers or anything else to help pull?

■

Do you pull one hair at a time, or do you pull hair in groups?

■

Do you pull with one or both hands? Which one?

■

Do you look at the hair after you pull? What are you looking for?

■

Do you put the pulled hair in your mouth, or rub it on your skin?

■

Do you rub the pulled hair between your fingers?

■

Do you save the hair? If so, what do you do with it later?

■

Do you just drop the hair on the floor?

Describing Pulling Signals

To be really aware of a problem, you need to be able to not only describe the problem but know when it is about to happen. In the case of pulling, your body is probably giving you signals or warning signs before you pull. These signs can be either things you do (e.g., stroking your hair, bringing your hand toward your head, etc.) or things you feel (e.g., thinking about pulling, thinking about which hair to pull, etc.) Work with your therapist to come up with three different pulling signals that you experience before you pull your hair. Write them in the space provided. My Pulling Signals 1. 2. 3. Acknowledging Pulling

At this point in the session, your therapist will begin to simulate pulling his or her own hair, as well as some of your pulling signals. Your job will be to point out the pulling and the signals when your therapist does them. This will get you used to detecting your own pulling episodes. You will continue these exercises for a few minutes or until your therapist is confident that you are able to recognize pulling and the warning signs of pulling. Next, your therapist will ask you to point out your own pulling and pulling signals. It is understandable to feel a little uncomfortable with this exercise. Many people with TTM do not pull their hair in public. For them, pulling is a very private experience. If you don’t wish to exhibit actual pulling, please feel free to act it out. Right after

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you pull, or simulate pulling, point it out by raising your index finger. Raising your finger informs the therapist that you are aware that occurrence of pulling happened. After you have completed all the exercises, you will move on to 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, when you are performing a competing response, it should be physically impossible for you to pull your hair. Second, it is something that you can do easily in almost any situation. Third, it is something you can do that is not noticeable to others. One of the most common competing responses for hair pulling is putting your arms down at your sides and gently clenching your fists for 1 minute whenever you feel your hands creeping toward your scalp or when you experience an urge to pull. Other examples of competing responses include folding your arms together, putting your hands in your pockets, or folding your hands. Work with your therapist to choose a competing response that will work for you. He or she will teach you how to do your chosen competing response for 1 minute as soon as you pull or as soon as you notice one of your warning signs. If the pulling or warning sign shows up right after the minute is up, use your competing response again for another full minute. When you first begin using your competing response, you may become frustrated because it may feel like you are using it all the time. This is normal and you will find that, over time, you will need to use your competing response less often. Also, be careful that you don’t give up your competing response as soon as you see improvement in your pulling. It is important to continue to use your competing response for as long as pulling is a problem for you.

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Stimulus Control Last week, you worked with your therapist to identify certain situations in which you find it hard to resist pulling. Today you and your therapist will discuss various things you can do to make pulling in these situations difficult. The stimulus control interventions you choose should adhere to three principals. First, they should not be used to prevent or avoid uncomfortable urges, feelings, or thoughts you may have. Second, they should be simple, easy to implement, and, when possible, not socially disruptive. Third, their only purpose is to make pulling more difficult and burdensome. Refer to the Stimulus Control Intervention Recommendations form for examples of interventions you can use. Work with your therapist to select the stimulus control techniques appropriate for you and complete the Stimulus Control Assignment Sheet provided.

Homework

✎ Continue monitoring your hair pulling on a daily basis using the TTM Self-Monitoring Form.

✎ Continue monitoring your urges to pull using the Monitoring Your Urge Form.

✎ Begin using your chosen competing response as soon as you pull, are about to pull, or when you experience one of your warning signs.

✎ Begin using stimulus control procedures.

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Stimulus Control Intervention Recommendations Setting

Bathroom

Possible Intervention

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 Games

1. Sit in the middle of a couch or on a chair with no armrests 2. On top of the television place a timer that you have to 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

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

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1. If pulling does not occur around others, try to recruit social-support people to be present in high-risk situations.

Stimulus Control Assignment Sheet Date Developed:

Date Implemented:

Location of Pulling: List strategies to implement for prevention of pulling from this site 1. 2. 3. 4. Location of Pulling: List strategies to implement for prevention of pulling from this site 1. 2. 3. 4. Location of Pulling: List strategies to implement for prevention of pulling from this site 1. 2. 3. 4. Location of Pulling: List strategies to implement for prevention of pulling from this site 1. 2. 3.

4.

15

16

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

MINUTES PULLING

DESCRIPTION OF

FEELINGS, THOUGHTS, OR

FEELINGS, THOUGHTS, OR

PULLING SITUATION

URGES BEFORE PULLING

URGES AFTER PULLING

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

Day 1

Day 5

1.

1.

2.

2.

3.

3.

Day 2

Day 6

1.

1.

2.

2.

3.

3.

Day 3

Day 7

1.

1.

2.

2.

3.

3.

Day 4 1. 2. 3.

17

18

Daily Graph of Progress

Measure of Progress

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Session 3: Valuing

Chapter 3

Goals ■

To discuss how trying to control your urges to pull gets in the way of living the life you want

Weekly Assessment At the start of the session, you will complete your weekly assessment and discuss it with your therapist. Be sure to plot your progress on the graph provided at the end of this workbook.

Homework Review After completing your weekly assessment, your therapist will review your homework assignments from the previous week. Come to the session with your homework completed and be prepared to discuss your reactions to the assignment(s). Plot the data from your daily self-reports on the graph provided at the end of this chapter.

Valuing Therapy is not just about reducing the pulling. We are sure you would like that outcome, but it is not really a goal in itself. Most people want to get their pulling under control because the act of pulling, time spent regulating the urges to pull, and time spent hiding the effects of pulling severely interfere with their lives. Therapy is about helping you live the life that you want, not just getting control of your pulling. It can help to clarify what therapy itself is about and what the struggle with urges and pulling is doing to your life. This is where values come in.

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Values are things that are important to you, things that you are willing to work toward even in the face of uncomfortable urges, thoughts, feelings, and bodily sensations, or what we like to call “private events.” Values are basically what we want to be about as human beings. Values are different than goals in that goals are short term and can be achieved. Stopping hair pulling is a goal and not a value. Being a loving parent is a value. Goals can be steps toward enacting values, but values can never be fully achieved. Values will always be there as sort of a “guiding light.” There will never be a time when a parent is “done” being loving to her child; even after a successful moment, the next opportunity presents itself. We are going to focus here on working toward your values, and will talk about how some of the things you are doing to try and control your urges may be taking you away from what is really important to you. Use the form provided to determine which of the areas in your life are affected by your attempts to control your urges. Please feel free to list as many or as few areas as you feel are necessary. The purpose of this form is to help you see what is important to you in your life and how pulling and other means of controlling urges, emotions, thoughts, and other private experiences have held you back from living the life you want.

How Has Fighting Your Urges Affected You Instructions: In completing this form, think about all the ways in which your struggles with urges to pull, thoughts about pulling, cravings to pull, or particular emotions have prevented you from doing something important to you. For each area, note how your life would be different if you did not have to deal with these struggles. It is unlikely that all areas are important to you, so only respond in accord with your values. Remember, these are your values, not someone else’s. 1. Marriage, couples, intimate relations

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2. Family relations

3. Friendships and social relations

4. Career and employment

5. Education, personal growth and development

6. Recreation and leisure

7. Spirituality

21

8. Citizenship

9. Health and physical well-being

10. Others

Another way you can determine your values is to ask yourself what you would want written on your tombstone. Use the space provided here to record your thoughts.

Writing Your Epitaph Instructions: On the following lines, please write what you want written about you on your tombstone. What do you want people centuries from now to know about you? What did you stand for? What was important about you?

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Summary This session is about doing what’s important to you. What do you want to be about? Do you want to be remembered for fighting your urges to pull, or do you want to be remembered for something bigger? Still, don’t forget that values are things that we get to pursue rather than hold as objects. It is similar to rock climbing being about the climbing rather than reaching the top of the rock. If reaching the top of the rock were the goal, there would certainly be easier ways to get there. Similarly, therapy and following values lie in the process rather than the outcome. Enjoy therapy and enjoy your life.

Homework

✎ Continue monitoring your hair pulling on a daily basis using the TTM Self-Monitoring Form.

✎ Continue monitoring your urges to pull using the Monitoring Your Urge Form.

✎ Also continue engaging in your chosen competing response and implementing stimulus control procedures.

✎ Spend time thinking about areas of your life that are really important to you and how pulling and struggling to pull have taken you away from these things.

23

24

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

MINUTES PULLING

DESCRIPTION OF

FEELINGS, THOUGHTS, OR

FEELINGS, THOUGHTS, OR

PULLING SITUATION

URGES BEFORE PULLING

URGES AFTER PULLING

Monitoring Your Urge Form Instructions: For each day, describe two to three times when you had a significant urge to pull your hair. Please describe what you were thinking and feeling as well as what you did with the urge (e.g., tried to stop it, tried to distract yourself from it, tried to relax it away, etc.)

Day 1

Day 5

1.

1.

2.

2.

3.

3.

Day 2

Day 6

1.

1.

2.

2.

3.

3.

Day 3

Day 7

1.

1.

2.

2.

3.

3.

Day 4 1. 2. 3.

25

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Daily Graph of Progress

Measure of Progress

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Session 4: Does Control Work?

Chapter 4

Goals ■

To talk about the strategies you use to try to control your urges to pull

■

To learn whether these procedures truly work in the long run

Weekly Assessment At the start of the session, you will complete your weekly assessment and discuss it with your therapist. Be sure to plot your progress on the graph provided at the end of this workbook.

Homework Review After completing your weekly assessment, your therapist will review your homework assignments from the previous week. Come to the session with your homework completed and be prepared to discuss your reactions to the assignment(s). Plot the data from your daily self-reports on the graph provided at the end of this chapter.

Barriers to Pursuing Values Today you will continue the discussion from last week about the barriers that stand in the way of living a life that is more meaningful to you. Think about the role that fighting with your urges plays in keeping you from leading a valued life. Think about the time you spend pulling, trying to control the urges to pull, and managing the effects of pulling and how it interferes with pursuing your values.

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What if all these things are just ways of dealing with your urges and other internal sensations and experiences that you don’t like? Take a close look at the effects of trying to control these thoughts, feelings, and bodily sensations on your quality of life.

Long-Term Utility of Control In this phase of the program, your therapist will help you recognize more clearly your struggle with your urges to pull. First, pulling, avoiding areas or situations that produce urges to pull, and any other attempts to reduce urges only work in the short term. These strategies can reduce urges to pull for minutes or hours, but they do not work for meaningful amounts of time. Second, these strategies are not effective strategies in the long term. The urge will show up at a later time. Third, not only do these strategies to control urges not work in the long term, but these strategies are more of a problem than the urge itself. What if you could only have the urge and no pulling— would there still be a problem? Really? What if it is not the urge that is the problem but the way you respond to the urge? We bet you are a little confused by these statements. So, don’t believe us, look at your experience. If you can honestly say that you are good at controlling your urges to pull for meaningful periods of time, and that these attempts are not negatively affecting your life, then great. But if you can’t say that, and you feel like you are falling further and further behind in this struggle, then maybe it is time for a different game. Refer to your completed Monitoring Your Urge forms from the last 3 weeks and ask yourself the following questions: 1. What do I do to control my urges to pull my hair (e.g., pull, avoid situations that make me want to pull or that cause me stress, rub cream on my head or use hairspray, etc.)? 2. How well do these strategies work in the short term? What about the long term? Does the urge to pull usually come back? 3. What are the costs or disadvantages of these strategies (e.g., hair loss, emotional upset, financial costs, loss of time that can be spent doing more pleasurable things, etc.)?

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4. Is my struggle with these urges getting greater or less over the months and years? Am I succeeding or falling more and more behind? Your answers to these questions should show you just how damaging your avoidance strategies can be. Pulling your hair to reduce aversive feelings or thoughts may increase feelings of relief and pleasure in the short term, but is generally ineffective and costly in the long term. Remember the two-games metaphor discussed in therapy when considering how helpful controlling these private experiences can be.

Homework

✎ Continue monitoring your hair pulling on a daily basis using the TTM Self-Monitoring Form.

✎ Also continue engaging in your chosen competing response and implementing stimulus control procedures.

✎ Use the Private Event page at the end of the chapter to write down a private event that you are trying to control by pulling your hair. For example, maybe you pull certain hairs because you perceive them to be uneven or coarse. Write this thought on the form on page 32 (or 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.

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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

MINUTES PULLING

DESCRIPTION OF

FEELINGS, THOUGHTS, OR

FEELINGS, THOUGHTS, OR

PULLING SITUATION

URGES BEFORE PULLING

URGES AFTER PULLING

Daily Graph of Progress

Measure of Progress

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

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In the space provided, 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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Session 5: Acceptance

Chapter 5

Goals ■

To understand that accepting your urges to pull may be a viable option for managing your pulling and leading a more valued life

■

To process the private-event homework exercise from last week

■

To practice accepting your unwanted thoughts and emotions related to pulling by participating in behavioral commitment exercises

Weekly Assessment At the start of the session, you will complete your weekly assessment and discuss it with your therapist. Be sure to plot your progress on the graph provided at the end of this workbook.

Homework Review After completing your weekly assessment, your therapist will review your homework assignments from the previous week. Come to the session with your homework completed and be prepared to discuss your reactions to the assignment(s). Plot the data from your daily self-reports on the graph provided at the end of this chapter.

Accepting Private Events (Willingness) Last week you learned that the strategies you use to control your urges to pull have been largely unsuccessful over the long run. Try33

ing to not think about pulling, trying to suppress urges or emotions related to pulling, avoiding places and emotions that occasion pulling, or engaging in actual pulling gets in the way of you leading a values-rich life. The more you work to control the things that lead to pulling, the more you are taken away from what you really want to do with your time. Learning to accept the unpleasant private events (thoughts, urges, bodily sensations) that come before pulling allows you to experience those feelings without letting them interfere in your pursuit of your life’s values. Acceptance is about embracing your unwanted thoughts and feelings (e.g., urges to pull, thoughts about pulling). Acceptance is not about accepting that you pull your hair. The idea is to accept what your mind is saying and end your struggle with these unpleasant private events by not trying to get rid of them or change them. It is a way of taking an active stance toward your urges. You can choose to accept them and let them be, or you can fight with them. .

This might be a little confusing because it is such a different way of looking at your situation; but honestly, have the steps you’ve taken up to this point given you control of your life? Or does it feel like your trichotillomania has taken control? By taking control over the way you respond to your urges to pull, you are regaining control of your life. You still will not have control over your urges, but that is nothing new. Did you really have control before? Acceptance is about gaining control of your life by giving up trying to control your urges to pull. We bet that it is uncomfortable to think about not trying to control your urges. To help you understand the concept of acceptance, don’t do anything with your thoughts about whether it will work or not. Just notice that your mind is telling you whether or not this is a “good” idea. Just notice the feeling of anxiety you are having and experience your confusion without fighting it. Of course, this is not how people usually experience their thoughts and emotions. They usually think about things, make informed decisions, plan, etc. But honestly, has all that hard work helped you get control of your urges in the long run?

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Private Event Exercise For homework last week, your therapist asked you to write down a private event that you are trying to control by pulling your hair. He or she then asked you to carry the piece of paper you wrote on in your shoe. Although this seemed like an odd request, the exercise actually has multiple purposes. The first day you walked around with the paper in your shoe, you may have found that you were constantly adjusting your shoe and moving the paper around. As time went on, however, sometimes you felt the paper and sometimes you didn’t. When you did feel the paper and tried to do something about it (e.g., move it to a different spot in your shoe), you were overly focused on it and likely felt the presence of the paper more strongly. Sometimes you would go hours and not even notice that you had the paper in your shoe. Does this sound familiar? This is just like your urges to pull. Sometimes they are there and sometimes they aren’t. They show up randomly. However, the one guarantee is that when you try to deal with your urge directly by trying to control it, reason with it, or pulling your hair to make it go away, you will find it to be so much more present for you. It is almost as though the more you try to manage the urge, the stronger it becomes. We would never promise that if you leave your urge alone it will go away—that won’t work either. But did you notice the natural ebb and flow of the urge when you weren’t engaged with it? When you leave the urge to pull alone, sometimes it shows up, and sometimes it goes away. Acceptance allows it to do what it naturally needs to do. There is no offer that it will go away, but what’s the point in fighting a battle that can never be won? Put your resources somewhere else. It is important to understand that the purpose of treatment is not to get you to accept your pulling, but rather to accept your urges to pull. The rule with urges is, the more you try to control them, the more you have them. You can either have your urges and resent them every day, or willfully invite them in.

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Acceptance of Urges versus Acceptance of Non-valued Behavior Up to this point, you and your therapist have spent some time discussing control strategies for actual pulling, and recently the focus has been on teaching you to be willing to accept unpleasant thoughts, images, urges, or emotions (private events) involved in your pulling. However, at no point during the course of therapy was there a discussion of accepting the actual pulling. In Session 2 you were introduced to habit reversal training (HRT ) as a technique you can use to control your actual hair pulling. HRT is also useful in helping you stop engaging in behaviors that don’t allow you to follow your values. You may have noticed already that when you stop pulling, unpleasant private experiences sometimes come up, which is why you worked on being willing to have those experiences. This program has given you a tool to stop your pulling, as well as prepared you to handle a lot of the unpleasant private “stuff” you use pulling to control.

Behavioral Commitments From this session on, your therapist will work with you to help you find opportunities to practice following your values while practicing acceptance and the other skills that will be covered in future sessions. These practices are called behavioral commitment exercises and they are part of the acceptance and commitment therapy (ACT ) phase of the treatment program. You will be asked to find areas of your life that you have given up or that are not how you want them to be because of your struggle against your urges to pull. Do you spend more time in the washroom pulling your hair (to control the urge) than you do with the people you care about? Do you avoid situations because they might make you want to pull, even though those activities are important to you? Your therapist will work with you to help you get back into those situations so that you can start doing what is important to you—even when your urges are present. Behavioral commitments also give you opportunities to practice the work that you do in session with your therapist. It is similar to working with a coach, but then going out and practicing on your own. Most of the skill building occurs when you are out practicing, in between sessions.

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These exercises will teach you how to stop yourself from attempting to regulate or change private events associated with pulling. Read the Behavioral Commitment Instructions provided on the next page and work with your therapist to complete the Behavioral Commitment Worksheet at the end of this chapter.

Homework

✎ Continue monitoring your hair pulling on a daily basis using the TTM Self-Monitoring Form.

✎ Also continue engaging in your chosen competing response and implementing stimulus control procedures.

✎ Using the Behavioral Commitment Worksheet, practice the agreed-upon behavioral commitment exercise on a daily basis over the course of the week.

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Behavioral Commitment Instructions Behavioral commitment exercises involve answering three questions and following three rules. Three Questions

Where will the commitment take place?

What you are committing to doing?

What tools can you use to help you keep this commitment?

Three Rules

1. Success is determined by whether you kept the assigned task, not whether it was easy or hard, comfortable or uncomfortable, or urge-free or urge-filled. 2. During the exercise, you should be open to experiencing all urges, feelings, thoughts, or emotions freely and fully, even if they aren’t pleasant. 3. Remember that the point of this exercise is not to make you feel better. It is to challenge you to commit to a course of behavior and make room in your mind for whatever shows up.

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Behavioral Commitment Worksheet Instructions: Please list and describe as many situations as you can think of when your urges to pull, thoughts about pulling, or emotions that predict your pulling are likely to occur. Also, consider situations in which pulling or trying to control the urge has directly affected your ability to carry out valued behaviors. What valued activity could you commit to doing, regardless if your urges show up? Situation 1:

Situation 2:

Situation 3:

Situation 4:

Situation 5:

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40

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

MINUTES PULLING

DESCRIPTION OF

FEELINGS, THOUGHTS, OR

FEELINGS, THOUGHTS, OR

PULLING SITUATION

URGES BEFORE PULLING

URGES AFTER PULLING

Daily Graph of Progress

Measure of Progress

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

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Sessions 6 & 7: Defusion from the Literal Meaning of Language: You Are Not Your Urges

Chapter 6

Goals ■

To learn that your urges to pull, thoughts about pulling, and pulling-related emotions are not real things that need to be treated literally

Weekly Assessment At the start of the session, you will complete your weekly assessment and discuss it with your therapist. Be sure to plot your progress on the graph provided at the end of this workbook.

Homework Review After completing your weekly assessment, your therapist will review your homework assignments from the previous week. Come to the session with your homework completed and be prepared to discuss your reactions to the assignment(s). Plot the data from your daily self-reports on the graphs provided at the end of this chapter. Because this chapter covers two sessions over 2 weeks of treatment, we have provided two copies of the Daily Graph of Progress for your use. We have also included two copies of the TTM Self-Monitoring Form and the Behavioral Commitment Worksheet, as you will need these to complete your Session 6 and Session 7 homework assignments.

Defusion of Language This phase of therapy largely involves defusing the role of language in the exacerbation of pulling. Defusing language means seeing 43

thoughts, feelings, and bodily sensations as what they really are— just thoughts, feelings, and bodily sensations. They are not real things. For example, if you resist an urge to pull your hair, you may feel tense or stressed out and say to yourself, “If I don’t pull this hair, I’m going to go crazy!” We often treat these thoughts and feelings as real and “dangerous” things—as though they could actually harm us. But what if these are not real events? What if these are only words in our heads, and natural emotional states? One part of defusion is the ability to see that the thoughts you have are separate from you as a person and that thoughts and feelings affect the way you experience the world. Your mind never stops working; it always has something say. You don’t have a choice as to whether or not thoughts about pulling are going to show up when you are in certain situations (e.g., in the bathroom, after a disagreement with someone close to you, after a stressful day at work, etc.). However, you do have a choice of whether or not you “buy into them.” The question is not how to stop yourself from having these thoughts, urges, and emotions, but how can you recognize these experiences for what they really are: activity in your brain that has little relation to what you do unless you choose to let it.

Being Present Exercise The following exercise will help you become more aware of what you are thinking. The function is not to help you relax or hypnotize you. The function is to help you become more aware of your thinking and to notice how ingrained this process is. There will be moments when you will be able to do the exercise and watch your thoughts go by, and there will be moments when the exercise has completely stopped—the play will be gone—and you have “bought into a thought.” We want you to be able to see the difference between experiencing a thought and buying into a thought. 1. Close your eyes or stare at a blank spot on the wall. 2. 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. Notice that there is a temperature difference as it

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comes back out. Notice what your belly feels like as it lowers and rises. Notice who is noticing these things. It is you. 3. Now listen to the different sounds that are in the room. There are the loud, obvious ones like the fan in the computer, but there are more subtle ones like the sounds in the hall or outside. See if you can’t notice those. As you listen to these sounds, notice who is hearing them. 4. 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 you don’t like, that you might want to get rid of. Just notice that urge to get rid of them and continue watching your thoughts on the stage. 5. 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 would in a real play. There will be moments when you are no longer doing the exercise and are only thinking. If this happens, you are “buying into” your thoughts, and you should bring yourself back to the exercise (watching your thoughts on stage) and get it going again. Practice this exercise for about 10 minutes every day until the next session.

Defusion Exercises In these sessions, you and your therapist will work on many exercises, all with a similar purpose: to demonstrate through examples and metaphors that your thoughts, urges, emotions, and other private experiences are simply your mind at work. They do not have to have any specific control over what you do. How you feel, what you

45

think, and the urges you may have can be independent of how you live your life and of the actions you take. Following is a list of many different metaphors and exercises your therapist may share with you in therapy. Brief summaries of each are provided here as a reminder. You may review or repeat them if you find that your thoughts, urges, and emotions seem to be exerting control over your actions. Tree-on-the-Road Metaphor

Are you treating your thoughts, feelings, and bodily sensations about pulling as real things—like trees that have fallen on your road—or like warnings that a tree has fallen? Trees are in the way. Warnings are not real things that have to stop you. Choice Metaphor

Remember how you tried to make your therapist walk, using only words or other private experiences. Who controls your behavior, the private experiences or you? Whose choice is it to act? Acting without Reasons

Your mind will always give you reasons why you should pull, and it will also give you reasons why you shouldn’t pull. What it comes down to is making the “choice” to pull or not. A choice is when you act without reasons. The mind is not involved in choices. Decisions are made by your mind when you have reasons for doing what you’re doing. Because you came up with reasons for and against pulling, you need to set your mind aside and simply make a choice on whether or not to pull. Reasons will not help you here. Playing with Your Urges in a Different Way

People with TTM often take their urges to pull hair very seriously and literally. Because of this, it is often helpful to interact with the thoughts, feelings, and bodily sensations that accompany your pulling in a different, slightly silly way. Remember how you described

46

your urge to your therapist in session? Was it an animal? A commercial? A wrestler? Describe its details. Be silly about it. Evaluation versus Description

This exercise focused on helping you experience your urges to pull and thoughts about pulling more as they actually are and less as what your mind tells you they are. Remember, in a factual way, urges are not dangerous things. No feeling is actually dangerous, but the way you respond to it can be dangerous. It is the pulling to get rid of the urge, the avoiding of social situations so as not to feel embarrassed, or the avoiding of relationships that is a problem. We will seek out many of the same feelings that we try to get rid of if they have a different label. Many people will ride a roller coaster, but avoid a similar feeling of anxiety that comes with meeting a new person. But if you looked at these two feelings outside of the context and without the cognitive evaluations of them, they are pretty much the same. Riding a roller coaster and meeting a new person are similar in that they produce the same core feelings and sensations. You can’t stop yourself from interpreting your urges and thoughts about pulling the way you do, but if you can become more aware of the process that is taking place, you will be able to see them for what they are, and acceptance of their presence will be easier. The next time you are struggling with the urge to pull, keep in mind what it really is. The Pull of Your Mind

Remember what your mind does when you make a particular statement. If you say, “There is nothing good about pulling,” your mind will automatically come up with something in response to that statement, such as, “Well, it does feel good when I do it.” Because your mind will often pull for the opposite of what you’re thinking, you can see that trying to reason your way out of an urge is very likely not possible. If you can’t stop the process, you can at least learn how to work with it.

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Take Your Urges with You

In this exercise you wrote your main thought about hair pulling on a 3 ⫻ 5 card and carried it with you every day. The purpose of this exercise was to help you see your thoughts about pulling and urges to pull in a different way. In the pulling moment, pulling-related thoughts and urges are felt as “bad and dangerous,” but outside of that moment they are easy to experience as just experiences. Talking for the Client

In this exercise your therapist pretended to be your mind. He or she spoke aloud what you may have been thinking. The purpose of this exercise was to demonstrate that you can separate the chatter of your mind from what you actually choose to do.

Homework

✎ Continue monitoring your hair pulling on a daily basis using the TTM Self-Monitoring Form.

✎ Also continue to engage in your chosen competing response and implement stimulus control procedures.

✎ Practice the Being Present exercise for 10 minutes every day until the next session.

✎ Complete the behavioral commitment for next week. Following the Behavioral Commitment Worksheet, continue with commitments to not pull.

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Behavioral Commitment Worksheet Instructions: Please list and describe as many situations as you can think of when your urges to pull, thoughts about pulling, or emotions that predict your pulling are likely to occur. Also, consider situations in which pulling or trying to control the urge has directly affected your ability to carry out valued behaviors. What valued activity could you commit to doing, regardless if your urges show up? Situation 1:

Situation 2:

Situation 3:

Situation 4:

Situation 5:

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Behavioral Commitment Worksheet Instructions: Please list and describe as many situations as you can think of when your urges to pull, thoughts about pulling, or emotions that predict your pulling are likely to occur. Also, consider situations in which pulling or trying to control the urge has directly affected your ability to carry out valued behaviors. What valued activity could you commit to doing, regardless if your urges show up? Situation 1:

Situation 2:

Situation 3:

Situation 4:

Situation 5:

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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

MINUTES PULLING

DESCRIPTION OF

FEELINGS, THOUGHTS, OR

FEELINGS, THOUGHTS, OR

PULLING SITUATION

URGES BEFORE PULLING

URGES AFTER PULLING

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52

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

MINUTES PULLING

DESCRIPTION OF

FEELINGS, THOUGHTS, OR

FEELINGS, THOUGHTS, OR

PULLING SITUATION

URGES BEFORE PULLING

URGES AFTER PULLING

Daily Graph of Progress

Measure of Progress

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

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Daily Graph of Progress

Measure of Progress

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Session 8: Practicing Acceptance and Commitment Therapy (ACT)

Chapter 7

Goals ■

To participate in exercises that will show you that you can experience urges to pull without pulling

Weekly Assessment At the start of the session, you will complete your weekly assessment and discuss it with your therapist. Be sure to plot your progress on the graph provided at the end of this workbook.

Homework Review After completing your weekly assessment, your therapist will review your homework assignments from the previous week. Come to the session with your homework completed and be prepared to discuss your reactions to the assignment(s). Plot the data from your daily self-report on the graph provided at the end of this chapter.

Embracing the Urge A lot of work has taken place in the therapy sessions. You have done some work showing you that your urges to pull are incredibly difficult, if not impossible, to control and that attempts to control them are often more of a problem than the urges themselves. Therefore, learning to accept their presence in your life might be a more useful way to address them. You’ve also learned that your urges are not the same as they present themselves to be.

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In this session you will work with your therapist on exercises that will put your new knowledge to the test. During these exercises you will practice making room for your urges to pull. In order to conduct these exercises, you will need to experience the urge to pull so that you can practice functioning with it. You will pick a specific behavior that makes you want to pull your hair and engage in it for a specific amount of time determined by you and your therapist. For example, you may agree to stare in a mirror or hold a pair of tweezers for 10 minutes. You may agree to actually pull a hair. The goal is to give you a chance to practice using the skills that you have learned. Think about the values you are working toward (see Chapter 3) and remind yourself that this exercise is in the service of those values. During this time, it may seem like you are undoing some of the stimulus control interventions you have been doing, and this may seem a bit scary or confusing. You need to make room in your mind for these feelings and allow yourself to experience whatever shows up when you start doing these urge-provoking activities.

General Guidelines for Practicing to Function with Urges If you are unsure about the procedures involved or the purpose of these exercises, please discuss this with your therapist. Following are a few guidelines to help you complete the exercise in a way that helps teach these skills. 1. Set specific parameters on the exercise that involve time or activity. For example, you might look in the mirror for 10 minutes without pulling. 2. The exercise is not guided by level or severity of any thought, feeling, or bodily sensation. The exercise will last for the amount of time you specify; it does not end when the urge gets too high or you are too tired. 3. The success of the exercise is not dependent on how much anxiety you feel or how intense your urges are. The focus of the exercise is to practice being as open and willing as you can possibly be for the amount of time specified. We can’t guarantee how much of the urge will show up, but we can control how

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open you are to the possibility of it showing up. Even if no urge shows up, the exercise was successful if you were open to the possibility. Remember, urges are not under our control; they will come and go. 4. It is your choice to do these exercises. Say “yes” and mean it, and say “no” and mean it. Pick something that you are truly willing to do. This exercise cannot be done half-way. It is like jumping off a diving board: you either do it or you don’t. If your therapist is suggesting something that you will not actually do or will only do half-way, let him or her know. Be clear about exactly what you are willing to do. Agreeing to complete a smaller exercise is much more useful than agreeing to a large one and not doing it.

Homework

✎ Continue monitoring your hair pulling on a daily basis using the TTM Self-Monitoring Form.

✎ Also continue to engage in your chosen competing response and implement stimulus control procedures.

✎ Complete the Making Friends with Your Urges form as a way to identify those situations where urges and other private events surrounding pulling are likely to occur.

✎ Complete behavioral commitments for next week. Following the Behavioral Commitment Worksheet, continue with commitments to not pull.

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Making Friends with Your Urges 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

Describe the situation

Describe your urge or

How did you manage

Describe your feelings

Describe your thoughts

other bodily sensations

these experiences in

in this situation

in this situation

during this situation

this situation?

Behavioral Commitment Worksheet Instructions: Please list and describe as many situations as you can think of when your urges to pull, thoughts about pulling, or emotions that predict your pulling are likely to occur. Also, consider situations in which pulling or trying to control the urge has directly affected your ability to carry out valued behaviors. What valued activity could you commit to doing, regardless if your urges show up? Situation 1:

Situation 2:

Situation 3:

Situation 4:

Situation 5:

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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

MINUTES PULLING

DESCRIPTION OF

FEELINGS, THOUGHTS, OR

FEELINGS, THOUGHTS, OR

PULLING SITUATION

URGES BEFORE PULLING

URGES AFTER PULLING

Daily Graph of Progress

Measure of Progress

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

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Session 9: Practicing ACT and Review of Treatment

Chapter 8

Goals ■

To continue engaging in exercises from last session

■

To review what you have learned during the course of treatment

Weekly Assessment At the start of the session, you will complete your weekly assessment and discuss it with your therapist. Be sure to plot your progress on the graph provided at the end of this workbook.

Homework Review After completing your weekly assessment, your therapist will review your homework assignments from the previous week. Come to the session with your homework completed and be prepared to discuss your reactions to the assignment(s). Plot the data from your daily self-report on the graph provided at the end of this chapter.

Continue Embracing the Urge During this session, you will continue to work with your therapist to conduct exercises that will put your new skills to the test. Again, you will practice making room for your urges. Remember, these exercises will help you practice accepting your urges to pull without fighting against them. Like last week, you will pick a specific behavior that makes you want to pull your hair and engage in it for a specific amount of time determined by you and your therapist. For example,

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you may decide to stare in a mirror or hold a pair of tweezers for 10 minutes. You may even agree to actually pull a hair. The goal is to give you a chance to practice using the skills that you have learned. Think about the values you are working toward (see Chapter 3) and your motivation to commit to changing your behavior and being successful. During this time, it may seem like you are undoing some of the stimulus control interventions you have been doing, and this may seem a bit scary or confusing. You may need to make room in your mind for these feelings and allow yourself to experience whatever shows up when you start doing these urge-provoking activities.

Possible Difficulties Following are a number of possible difficulties that may occur when doing these exercises. They may or may not apply to you. 1. “What if the urge never goes away during the exercise?” Or, similarly, “what if it never shows up?” This is a very common concern. Both of these questions address a similar issue regarding your actual control over your urges. The truth is that urges to pull hair really work under their own rules and do not completely conform to events in your life. They might be stronger on “difficult” days, but we are willing to bet that there have been some difficult days when there were no urges. Thus, the purpose of the exercise is to practice being open to the possibility of the urge showing up. If is shows up, great, if not, that is fine too. If you were more open, you did the exercise. 2. “What if I started the exercise and it was too much for me?” If you find that an urge is “too much” then you are obviously treating the urge as a real thing. Sure, urges present themselves as scary, big, and dangerous, but they are not real in the way that this book is real. You might need some more practice with the defusion exercises in Chapter 6 of this book. 3. “What if I pulled hairs during or after the exercise?” Or, “I did a bad job with the exercise.” Life is really a series of opportunities to make choices. Some choices will be consistent with our values and some won’t be. At any time, even in the middle of

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an exercise, you have the opportunity to choose to do things differently. If you pulled 1 or 100 hairs, you are at a point where you can choose to continue to struggle against the urge or start accepting it and stop pulling. If the exercise did not go as you would like, you may do it again. 4. “What if I can’t get up the motivation to do the exercise?” Motivation is a thought and a feeling. It has the same properties as urges to pull hair—sometimes it will be there, and sometimes it won’t. You can choose to have motivation to control your behavior or you can choose not to. Have you ever not been motivated to go to school or work? Sometimes we follow our thoughts and feelings and sometimes we don’t. Sometimes motivation to do the exercise will be present and sometimes it won’t. Mostly, we do things because they are important to us. What is there to gain from doing the exercise?

Treatment Review Don’t forget that part of the purpose of these exercises is to give you opportunities to practice the concepts presented earlier in therapy. The following is a list of important concepts and skills you have learned in this program. ■

There are two different types of pulling: focused and nonfocused, or automatic pulling.

■

Habit reversal training, or HRT, focuses on controlling pulling, and acceptance and commitment therapy, or ACT, is more about learning to step out of the struggle with urges and other private experiences.

■

Review the benefits of moving in a valued direction over focusing energy on controlling a feeling.

■

What does your experience tell you about the long-term effectiveness of trying to control urges to pull hair?

■

Are your attempts to control the urge the problem or is it the urge? Could you live with the urge alone and no pulling?

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■

Instead of trying to control the urge, another option is to make room for the urge in your life—through acceptance.

■

Your urge is not a real thing that you have to fight with. Much of the power that our thoughts and feelings have comes from us. They are not intrinsic properties of the urges.

■

We work hard to make room for the urges and gain control over the pulling because this is important to you, not because you have to.

■

These are all skills that one needs to practice to stay good at them.

Homework

✎ Continue monitoring your hair pulling on a daily basis using the TTM Self-Monitoring Form.

✎ Also continue to engage in your chosen competing response and implement stimulus control procedures.

✎ Complete behavioral commitments for next week. Following the Behavioral Commitment Worksheet, continue with commitments to not pull.

✎ Think about potential barriers to maintaining the gains you’ve made in treatment.

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Behavioral Commitment Worksheet Instructions: Please list and describe as many situations as you can think of when your urges to pull, thoughts about pulling, or emotions that predict your pulling are likely to occur. Also, consider situations in which pulling or trying to control the urge has directly affected your ability to carry out valued behaviors. What valued activity could you commit to doing, regardless if your urges show up? Situation 1:

Situation 2:

Situation 3:

Situation 4:

Situation 5:

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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

MINUTES PULLING

DESCRIPTION OF

FEELINGS, THOUGHTS, OR

FEELINGS, THOUGHTS, OR

PULLING SITUATION

URGES BEFORE PULLING

URGES AFTER PULLING

Daily Graph of Progress

Measure of Progress

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

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Session 10: The End of Treatment

Chapter 9

Goals ■

To review what you have learned in this program

■

To learn about lapse and relapse and discuss relapse prevention techniques

■

To celebrate the completion of therapy

Weekly Assessment At the start of the session, you will complete your final weekly assessment and discuss it with your therapist. Be sure to plot your progress on the graph provided at the end of this workbook. The graph should show just how much progress you have made over the course of this program. Your pulling episodes have probably decreased dramatically and you are likely now able to see that your urges to pull are simply experiences in your mind that you can accept without having to act on them.

Lapse versus Relapse It is important that you be aware of the possibility that there may be occasions when your pulling starts to increase and you find that you are spending less time working on the problem and more time trying to control it. If this happens, we consider it a lapse, rather than a complete relapse. A lapse is a slip or partial loss of improvement. Lapses may be more common during certain situations or personal problems, or they may simply be due to lack of practice of the skills you’ve learned in treatment. If you experience a lapse, take it as a sign that you need more practice. Continued practice of your skills can prevent a lapse from turning into a relapse. From our experience, it

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is very easy to get back on track after a lapse because you have the skills from your therapy sessions. It is like not riding a bike for a couple years and then getting back on one. You will be a little shaky, but it will not take you very long to get back into it, in contrast to someone who has never ridden a bike. A relapse represents a full and persistent return to your old behaviors. Relapses typically begin as lapses that are not addressed. As mentioned earlier, they can be prevented if you are able to once again apply the skills you’ve learned in therapy.

Vigilance in Using HRT It is very important that you maintain vigilance in using the HRT techniques you have learned. As people experience success in using HRT, they often become less compliant with the procedure. To ensure that this doesn’t happen, it may be useful to schedule daily practice sessions during which you practice the HRT procedures on simulated hair-pulling episodes.

Changes in the Way You Respond to Your Urges Many different processes were covered in the second part of this treatment. We talked about the important areas of your life that have been ignored because of fighting with your urges through avoidance and pulling. We discussed the utility of trying to control your urges and the possible negative consequences that go along with those attempts. We worked on seeing urges for what they are and not what your mind says they are. Finally, we worked on practicing these skills within and outside of sessions. After treatment ends, you may find that you sometimes react to your thoughts, urges, and emotions as if they were real events with physical characteristics; you may avoid situations that bring on the urge; and you may find that you are not doing what is important to you on a daily basis. If you notice this happening, you are likely falling back into old patterns of thinking that internal experiences have control over you and, in turn, trying to control them. Revisit the exercises presented in this workbook and

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practice them on a daily basis. You may even need to set up some additional sessions with your therapist. A brief refresher might be all you need to get off that track and back onto one that works.

Celebrating the Completion of Therapy Congratulations! You have successfully completed treatment. Going through all 10 of these sessions was quite a ride. We hope that you have made the progress you were looking for. Take a moment and think about what you did to get yourself to this point. What are you doing differently than before you started treatment? Is the way you are living your life more consistent with how you want it to be? We hope the changes have been worth the time. If you keep working with what you’ve learned you will continue to improve or maintain the gains you have already achieved.

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Weekly Graph of Progress

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6

k1

We e

5

k1

We e

4

k1

We e

3

k1

We e

2

k1

We e

1

k1

We e

0

k1

We e

k9

We e

k8

We e

k7

We e

k6

We e

k5

We e

k4

We e

k3

We e

k2

We e

k1

We e

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Weekly Graph of Progress

Measure of Progres

Appendix

Assessment Measures

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The Milwaukee Inventory for Styles of Trichotillomania–Adult Report Please choose a number which best represents how the question fits your hair-pulling behavior. 0 ——— 1 ——— 2 ——— 3 ——— 4 ——— 5 ——— 6 ——— 7 ——— 8 ——— 9 not true true for about true for for any of my half of my pulling all of my pulling pulling 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. Scoring Instructions

Add your scores for questions 4–6, 8–11, and 13–15. This total represents the level of your focused pulling. Add your scores for questions 1–3, 7, and 12. This total represents the level of your automatic pulling. The higher the score, the more you are engaging in that particular type of hair pulling. Source: Flessner, C. A., Woods, D. W., Franklin, M. E., Cashin, S. E., Keuthen, N. J., and the Trichotillomania Learning Center Scientific Advisory Board. (In press). The Milwaukee Inventory for Subtypes of Trichotillomania-Adults (MIST-A): Development, exploratory factor analysis, and psychometric properties. Journal of Psychopathology and Behavioral Assessment.

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Acceptance and Action Questionnaire (AAQ) Below you will find a list of statements. Please rate the truth of each statement as it applies to you. Use the following scale to make your choice. 1 ————— 2 ————— 3 ————— 4 ————— 5 ————— 6 ————— 7 never very seldom seldom sometimes frequently almost always true true true true true always true true 1. I am able to take action on a problem even if I am uncertain what the right thing to do is. 2. I often catch myself daydreaming about things I’ve done and what I would do differently next time. 3. When I feel depressed or anxious, I am unable to take care of my responsibilities. 4. I rarely worry about getting my anxieties, worries, and feelings under control. 5. I’m not afraid of my feelings. 6. When I evaluate something negatively, I usually recognize that this is just a reaction, not an objective fact. 7. When I compare myself to other people, it seems that most of them are handling their lives better than I do. 8. Anxiety is bad. 9. If I could magically remove all the painful experiences I’ve had in my life, I would do so. Scoring Instructions

To calculate your score, add your ratings for all items. Be sure to reverse your scores for items 1, 4, 5, and 6 (i.e., 1 ⫽ 7, 2 ⫽ 6, 3 ⫽ 5, 4 ⫽ 4, 5 ⫽ 3, 6 ⫽ 2, 7 ⫽ 1). For example, if you rated item 4 as a 7, you would change that to a rating of 1 for purposes of determining your total score.

(Reprinted with permission. Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., Polusny, M., A., Dykstra, T. A., Batten, S. V., Bergan, J., Stewart, S. H., Zvolensky, M. J., Eifert, G. H., Bond, F. W., Forsyth J. P., Karekla, M., & McCurry, S. M. (2004). Measuring experiential avoidance: A preliminary test of a working model. The Psychological Record, 54, 553–578.)

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Acceptance and Action Questionnaire for Trichotillomania (AAQ-4TTM) Below you will find a list of statements. Please rate the truth of each statement as it applies to you. Use the following scale to make your choice. 1 ————— 2 ————— 3 ————— 4 ————— 5 ————— 6 ————— 7 never very seldom seldom sometimes frequently almost always true true true true true always true true 1. I am able to not pull when the urge to pull is strong. 2. I often catch myself daydreaming about my pulling and what I would do differently next time I feel the urge to pull. 3. When I feel the urge to pull, I am unable to take care of my responsibilities. 4. I rarely worry about getting my urges to pull under control. 5. I’m not afraid of my urges to pull. 6. When I evaluate my urges to pull negatively, I usually recognize that this is just a reaction, not an objective fact. 7. When I compare myself to other people, it seems that most of them are handling their lives better than I do. 8. Urges to pull are bad. 9. If I could magically remove all my painful experiences related to pulling, I would do so. Scoring Instructions

To calculate your score, add your ratings for all items. Be sure to reverse your scores for items 1, 4, 5, and 6 (i.e., 1 ⫽ 7, 2 ⫽ 6, 3 ⫽ 5, 4 ⫽ 4, 5 ⫽ 3, 6 ⫽ 2, 7 ⫽ 1). For example, if you rated item 4 as a 7, you would change that to a rating of 1 for purposes of determining your total score.

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About the Authors

Douglas W. Woods received his Ph.D. in clinical psychology from Western Michigan University in 1999. He is currently associate professor of psychology and Director of Clinical Training at the University of Wisconsin-Milwaukee. 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 member of the Trichotillomania Learning Center’s Scientific Advisory Board and the Tourette Syndrome Association’s Medical Advisory Board. He has published over 100 journal articles and book chapters on these and related topics, including two books, Tic Disorders, Trichotillomania, and Other Repetitive Behavior Disorders: A Behavioral Approach to Analysis and Treatment, and Treating Tourette Syndrome and Tic Disorders: A Guide for Practitioners. 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 received his Ph.D. from the University of Nevada, Reno, in 2007, and completed his clinical psychology internship at the Anxiety Disorders Clinic at the University of British Columbia. He is currently an assistant professor in the Department of Psychology at Utah State University in Logan, Utah. His research has generally focused on the treatment of OCD and OCD spectrum disorders such as trichotillomania and skin picking. He has authored over 40 scholarly pieces on areas such as OCD and OCD spectrum disorders, habit reversal, and acceptance and commitment therapy (ACT ). He is author of ACT Verbatim for Depression and Anxiety: Annotated Transcripts for Learning Acceptance and Commitment Therapy with Steven C. Hayes, Ph.D. His work on the application of ACT to OCD and OCD spectrum disorders has been funded by the National Institute of Health (with Steven Hayes) and the Trichotillomania Learning Center (with Douglas W. Woods).

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