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Beating Trichotillomania with Habit reversal

Updated: Feb 9

All our life so far as it has definite form is but a mass of habits.*

Life is a mass of habits; we often do the same thing, eat the same food, get up at the same time, go to the same places, drive the same route, … Many of our habits are ones we want to keep, they serve us well. We don’t particularly think about them, they simply happen. They provide a certain ritual and comfortable, safe routine in our lives.

Habits aren’t always good and wholesome though. Some are downright nasty. And as anyone knows who has tried to stop an annoying body focused repetitive behaviour - nail biting, cheek chewing, skin picking, hair pulling - it can be difficult!

Note: In this article I focus on hairpulling. Habit reversal is equally as powerful with any BFRB.

I work with many clients who pull out their hair (trichotillomania). This compulsive body-focused repetitive behaviour distracts the sufferer from unpleasant feelings and thoughts, and gives a certain pleasure or release. At the same time, the resulting hair loss or thinness (eyebrows, eyelashes, hair) leads to embarrassment, shame, and a feeling of being out of control.

A permanent cycle

👉 Internal or environmental triggers that lead to pulling👉 Pulling out hair 👉 Feeling a certain release/satisfaction/pleasure 👉 Feeling disgust, shame, embarrassment, frustration at having pulled

Every habit and capability is confirmed and grows in its corresponding actions, walking by walking and running by running … therefore if you want to do something make a habit of it, if you don’t want to do that, don’t, but make a habit of something else instead’ **

Easier said than done with a BFRB (body-focused repetitive behaviour).

You WANT to stop, but at the same time, you feel COMPELLED to pull or pick. You just can’t seem to get out of the cycle.

the 4-step habit reversal protocol

Cognitive behavioural hypnotherapy and a client’s strong belief that she is worthy and capable of overcoming her compulsive behaviour can help her either stop or effectively manage what used to be out-of-hand.

One of the tools central to cognitive behavioural therapy for trichotillomania is habit reversal.

In essence, as Epictetus suggested all those centuries ago, one habit is replaced by another using a 4 step process : Awareness, Relaxation training, Competing response training and Relapse prevention

Habit Reversal was first introduced in 1973 by Azrin and Nunn in their book Habit control in a day***. It has since developed and is a central part of any compulsive behaviour recovery. Let's take a look at the four steps in a little more detail.


You gain clarity and awareness, about when, where, and how you pull and build precise knowledge concerning the feelings, thoughts, and behaviours associated with your hairpulling before, during, and afterwards.

When you dig forensically into your particular behaviour with your therapist, you bring all of its quirks and rituals out to the light of day.

You often discover that this annoying behaviour is fed and maintained by many other rituals and routines. Sometimes by changing and disrupting these routines, your hairpulling lessens.

One woman I worked with always sat in a particular chair as she hairpulled, when I asked her why, she told me it was the dog's armchair too. It didn't matter if her hairs were all over the chair, she just vacuumed them up with the others. When she realised that sitting in this armchair was part of the behaviour, she no longer sat there and her pulling reduced.

Another client who is a very active and sporty person would pull and also nibble the roots as she sat in front of the TV in the evening. She has two small children and a husband who works away and had got herself into this evening routine which didn't help her relax or release energy. When she realised this she engged a baby sitter a couple of evenings a week and got back to the gym. Her pulling reduced greatly.

I have many examples like this. When you can pinpoint the moments and places that you pull, you can start to put different behavioural solutions in place.

Pinpinting these key times and places is the difficult part as they are so enmeshed in a trance like, automatic behaviour. This is where your forensic investigative work with a therapist is invaluable.

Relax mind and body

You learn and practice exercices which bring calm, stillness and peace in your day and increase your ability to self-regulate your emotions. You discover that by conscious breathing, practising mindfulness, relaxation, and self-hypnosis techniques regularly you can distract your mind and body from urges and the ‘need’ to pull.

Your self belief in your ability to change this disruptive behaviour increases as you feel and experience the benefits of taking moments in your day to move from the constant busyness and doing, to its necessary counterpart of stillness and being. It is often here that a real shift occurs as you learn and can apply emotional, physical and mental self regulation.

This brings the following awarness:

  • You notice muscle tension more and can release it to soften your muscles and relax physically. When you are truly physically relaxed you do not hairpull.

  • You notice tight shallow breathing and can move this to a softer breath that drifts deeper down your body as you engage in a gentle, longer exhale. When your breathing is calm you do not hairpull.

  • You notice the busyness and overwhelm of your thoughts and can use techniques to calm and distance them. You learn to understand them and not get caught up in them. You also learn how to insert your own strong positive, helpful self nurturing thoughts instead of these ones that pollute your mind. When your mind is calm and positive you do not hairpull.

  • You practice moments of presence or mindfulness. This gathers you together in the NOW. When you are connected in now you do not hairpull.

Repetition is the key word here. If you do an exercise once in a while it won’t work. If you consistently and consciously dedicate time to them, guess what: you create new pattern and new positive self nurturing rituals in your day.

In my Headstrong programme I dedicate much time and importance to implementing these techniques and strategies. You learn 18 initial techniques to shift tension and anxiety during the programme. This toolkit is regularly added onto and you can download the new recordings.

Competing response

Once you have learned and integrated these exercises into your life, you are ready to put in place a strong counter behaviour which is the competing response to hairpulling. This consists of consciously changing your muscle movement and breathing pattern, and switching your thoughts as you repeat a coping statement.

It is the combination of this triad, Breath Movement, Thought, repeated with conviction, and focus that disintegrates your 'old' hairpulling coping strategy.

  • When you change your hand movement, bringing them down and resting your muscles you can't pull.

  • When you engage a conscous relaxing breath you connect with where you are NOW and do not pull.

  • When you have an empowering, personal statement that consolidates in one phrase your determination to be free from hairpulling you reconnect with your strength and you do not pull.

This technique needs practice and becomes stronger each time it is repeated. Being acccoutable and refining your practice with your therapist is an important part of its success.

Relapse prevention

Practice, practice, practice. As the days and weeks go by this counter response becomes more automatic, more ‘normal’. It strengthens your self-belief and trichitillomania dwindles from an urge that is compelling and intense to a distant irritation.

Many of my clients have been very surprised at how quickly the obsessive, intense urge to hairpull just goes away. This is not magic even though it might feel like it, it is due to your focused, repeated work.

You learn that if you pull out a hair it doesn't mean that you have 'failed', that 'it' has come back and that you will always hairpull. You can identify what has hapeened, what you need to put back into place or ajust and you can do this with ease.

You understand that you are in control. You can keep trichtoillomania away or you can let it back into your life. The choice is yours.

One client recently told me how she was almost crying with happiness as she walked down the road feeling free and light and no longer worrying about her hair. She is doing the work and is reaping the benefits

Relapse prevention helps take away the invasive fear that this behaviour can 'come back'. In my Headstrong programme I strengthen the client's understanding of their thoughts and show them how they can change any negative self sabotaging cognitions. When you change your thoughts, your mood and behaviour follow suit.

We also spend time focusing on the particular 'Trich' thoughts that can pollute and contaminate recovery: 'I'll pull one and then stop' or 'it doesn't matter if I pull a bit, I've been really good over the last few days/weeks/months .....'

Once my clients have graduated from the Headstrong Programme I run regular group catchups so that any problems are nipped in the bud, confidence and motivation bolstered and connections made to reinforce relapse prevention.

How does hypnosis reinforce the habit reversal protocol?

When you reinforce habit reversal with hypnosis, you deepen its impact and tap into your creative, powerful imagination and all of its resources to help and guide you.

Habit reversal is practical, logical and easily understood and fits perfectly into a cognitive behavioural therapy programme. It is well tested, well documented and it works!

You can gain even more confidence as you visualise yourself using it when in the focused, peaceful state of mind that hypnosis brings to you. Hypnosis opens you to the creative, intuitive, dreamy unconscious and helps new experiences take root in this powerful yet hidden part of your mind.

Just as a tree has as much going on underneath the ground and hidden to the naked eye as above it, so do we.

In effect, you help yourself by using more of your mind when you work with hypnosis: the objective, logical, rational part on the surface is further empowered by the intuitive, meditative, symbolic part underneath.

When a hypnotherapist guides you she will use her knowledge about your particular compulsive behaviour to strengthen the experience.

Hypnosis can be a very intense experience and some of the images it conjures up can stay with you and guide you for a very long time afterwards. It's a natural experience that everyone can learn to use and benefit from.

Trich takes a back seat

Trich never ‘goes away’ completely, however when you use these effective strategies it means you can choose never to ‘let it back in’ to your life.

It means you know how to stop yourself from pulling if that urge comes

It means that even if you pull one hair you can use your strategies to stop right there.

It means it no longer has a hold over your life and actions

You can gain control and BE in control


*William James in 1892, quoted by Charles Duhigg in his fascinating book The Power of Habit (2012) Penguin

**Epictetus Discourses quoted by Ryan Holiday and Stephen Hanselman in The Daily Stoic (2016) Profile Books

*** Habit Control in a day Azrin and Nunn 1973

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