Compulsive Hair Pulling (Trichotillomania) & Straight Talk

Professional Q&A with Claudia Miles, MFT

Compulsive Hair Pulling (Trichotillomania) & Straight Talk


Claudia-MilesClaudia Miles, LMFT specializes in compulsive hair pulling (trichotillomania or TTM) & skin picking disorders as well as addictions, depression and anxiety.  

Claudia has led numerous workshops and groups on trichotillomania for both sufferers and providers in cities throughout the U.S. including Kansas City, New York, LA, San Francisco, Washington D.C. and Chicago.

Claudia grew up in L.A. and attended UCLA and worked for a number of years in the music business, managing rock bands and working as a freelance writer and editor.  She lived in the Netherlands for a year prior to attending JFK University in the San Francisco Bay Area where she received her Master’s degree in 1996.

Claudia began her private practice in Marin County in 1996 and returned to L.A. in February 2013, moving her practice as well.  She does in-person psychotherapy and professional consultation at her L.A. office and also and also works with clients via Skype, phone and email.


How did you get involved in this field?  

No short answer to that one.  I knew from a young age that I wanted to help people, make a difference on the planet.  I volunteered for my first political candidate at age 14, and then became very involved in the “no nukes” movement.

Even at that age I noticed that the people involved in the peace movement… well, they weren’t very peaceful; they were angry all the time. Something seemed off about working for peace yet being so personally unhappy and angry so I took a step back from politics and became involved in the music business as a personal manager, although I continued to volunteer for various organizations.

Also, beginning when I was a kid, age 11, my parents sent me to therapy.  It wasn’t because I had trichotillomania, (which I did) but because I was a pretty emotional young person and my folks weren’t really sure how to handle that.  I was in therapy consistently for many years and because I began at such a young age it informed how I look at life.  I continued to attend therapy off and on throughout my 20s and 30s because I found it such a helpful tool for self-understanding.

Ironically, I never could tell my therapist about my trich. I had hair and was able to cover the damage well enough that she did not ask. I could not imagine telling a therapist that I pulled my hair out which really upset me since the only reply I could imagine getting was, “Well, why don’t you just stop?”  I didn’t know the answer to that and didn’t even know why I did it, so I continued pulling my hair out into my 20s.

I chose to leave the music business because I was “partying” way too much and I realized after 10 years I couldn’t continue to live that way.  I got into recovery and went to 12 step meetings and at the same time I began to confront my pulling.

I still didn’t know what I wanted to do for a living but my volunteer work led me to the L.A. Center for Living founded by Marianne Williamson; a nonprofit which supported people who were living with AIDS back in the 80s.  It was there that I was first asked to lead a visualization group for people who were dying.  It was really scary but I really wanted to do it so I read some amazing books on death and dying by Stephen Levine and forced myself to lead the group.  It was by leading that group that I finally found the peace that had eluded me for many years.

I remember being so nervous that the guys would think I was a fake, or wonder, “What is she doing leading this group?”, however, once I got there it hit me that these people who were dying, the last thing they were doing was wasting the life they had left by judging me.  More importantly, I realized I was there to be of service, not to make them like me.

Something shifted in me back then. I realized that self-consciousness made it impossible for me to help others and it kept me stuck in my ego.  It did not matter what anyone thought of me, it mattered that I showed up to make a difference. That’s how the idea of being a therapist began to form and soon after it became clear to me that this was what I wanted to do.

Also around this time, I began to admit to myself that my hair pulling really bothered me and that I needed to face it.  Prior to that I had never even talked about it but I decided I absolutely had to tell someone.

I was attending AA at that time and I had a sponsor who I thought would be the right person to tell.  I figured she would think I was crazy but I knew, at least, that she would not laugh at me. Keep in mind, this was before the internet so I had no idea that hair pulling was something anyone else did.  I truly thought I was insane, however, I screwed up my courage and I told my sponsor.  I told her that I pulled my hair out every day and that I had as long as I could remember and also that I did not know how to stop.

The pause after I said that was probably 15 seconds but it felt like forever.  It was such a big moment for me.  Then my sponsor said the very last words I ever expected to hear; she said to me: “I used to pull my hair every single day too and one day at a time, I have not done it for six months.”

This completely shocked me and took my breath away.  I now realize that the chances of the first person I ever told about my hair pulling not only having trich, but having trich and being in some kind of recovery, that was some kind of sign. I had no doubt about that.

Not only was I not alone, I actually had hope.  After pulling my hair out from age 3 until age 28, I had hope and I eventually parlayed that hope into ultimately becoming pull-free.  It was around this time that I began applying to grad schools to become a therapist.

My original goal wasn’t to work exclusively with people who had trich because there were, and are, many things I wanted to work with.  Once I got into grad school, however, I learned what trichotillomania was and realized it was important that I began reaching out to folks who had the disorder.

I found TLC (the Trichotillomania Learning Center) and began to see how widespread the problem was. They asked me to present workshops for them at their retreats and conferences all over the country, which I did. I met people from many places who were deeply affected by my talks and who shared with me how inspired they were.  I also gave workshops for parents and spouses of hair pullers as I saw how important it was that they also understood the problem.

My practice became about 50% people who were suffering from trichotillomania and then slowly began to include dermatillomania (compulsive skin picking [CSP]).  Today I work with many issues but often find that hair pullers and skin pickers need to address more pressing issues before we can focus on the their picking and/or pulling.


What are the signs that the behavior is a problem rather than an activity such as fidgeting or something that can be treated by a dermatologist? 

Dermatologists do not treat trichotillomania though they have contributed to the conversation because they know things about hair re-growth.

The standard treatment is cognitive-behavioral therapy, although I use a more holistic approach.  I may employ cognitive behavioral techniques, but in my opinion you need to treat the whole person for long term recovery.

The signs of needing treatment are related to one’s age and one’s level of concern.  Often parents panic when a kid begins twirling or pulling our hair at a young age and they want to rush and bring their child in for treatment to a therapist but young kids do not respond well to treatment for this and often they will simply grow out of the behavior.  If a child is age 3 to 10, I usually meet with the parents and help them learn to detach somewhat from the behavior and not to panic. In many cases kids may grow out of it if you don’t make it a big deal.

Once someone is concerned about the problem, whether they are 12 or 30, it’s time to get treatment and that treatment would be psychological.


When a person has TTM, are there medications (topical or psychotherapeutic) that you find to be effective?

The only substance that studies have indicated is actually highly effective for trichotillomania is an amino acid called NAC or N-Acetyl Cysteine, and just to be very clear, the FDA has not approved ANY medication for the treatment of TTM.* NONE.

Despjte this fact, SSRIs are often prescribed because 60 percent of people with trich are also suffering from another disorder like depression or anxiety which respond to medications.[1]


Are there activities that are associated with pulling? 

Common activities and locations are: Watching TV or movies, sitting at the computer (working or playing), studying, talking on the phone (especially to someone you don’t want to talk to and feel unable to get off the phone with), in bed going to sleep, in bed while waking up and driving.


Aside from a compulsion, an inner need to perform the behavior that provides the momentary relief, are there common reasons that people pull?  For instance curly eyelashes sticking together, ingrown eyebrows, dry patches of skin…  In other words, is there a discomfort that people complain about that in and of itself focuses attention on that specific area.   

Hair pulling is nearly always begun unconsciously.  Any reasons like the above are simply rationalizations people give themselves because they want to understand why it is happening.

These kinds of things MAY be a trigger to get someone to start pulling– they feel a coarse hair and pull at it, they pick at dry skin or zits, they are grooming unruly eyebrows — and the appetite gets whetted, the urge gets stimulated but the bottom line is, people pull because they have trich.


Can hair pulling go beyond destructive to dangerous?  Are there long term health consequences related to hair pulling? 

For the most part there really aren’t.


Does a person suffering from TTM pull all over their body?

They certainly can, but most common is for people to pull hair from one particularly area, or perhaps several specific areas.

My clients have mostly been head hair pullers or brow and lash pullers.  Some of them pull both from the head and the lashes/brows but they are in the minority. Some clients pull from the pubic area and legs and arms. I’ve also had male clients who pull from their face.

Legs and arms aren’t often the site of choice but are sites consciously chosen by the puller to do less damage to their head hair, lashes and brows.

The pubic area can serve as one of these secondary sites, but it is also an area that people are drawn to as a primary pulling site.


Your blog Help for Hair Pullers and Skin Pickers say that you have been “pull-free” for over 20 years.  Congratulations!  That’s an amazing achievement!  Was therapy instrumental in your recovery? 

I had been in therapy for many years prior to becoming pull-free and I did work on what I believe are the underlying issues; I became a more individuated, a more whole person.

My self-acceptance and worth are no longer dependent on the validation of others or even on doing things perfectly or “amazingly.”  I stopped feeling shame about who I am inside and started feeling compassion for myself as well as others.

When I became pull-free, it was the first year that TLC had formed.  There was no internet, I never asked a therapist about pulling because I did not want someone to say, “Why don’t you just stop?”, however the things I learned in my previous year in therapy, as well as in 12 step meetings, my volunteer work and in my own personal growth on many levels, all contributed to my recovery. Also, working with people who have trich is enormously helpful for me.


Are skin picking and TTM very different?

They are extremely similar.

One difference with skin picking is that it is more likely to be preceded by thoughts of wanting to pick to “get rid of” zits, to pick at dry skin, to clear out a scab, to have “perfect skin.”

Often people who pick wish for perfect skin and also suffer from body dysmorphic disorder.  They may do most of their picking in front of a mirror.  Some skin pickers however, pick unconsciously and not in front of a mirror.  Both are body-focused repetitive behaviors (BFRBs) and both put one into the “trance” or altered state that becomes addictive.


Do you treat people in an individual setting or a group therapy?  Why? 

Both are effective for different reasons.

I’ve done a lot of group work, at various times having four therapy groups for hair pullers and skin pickers going at once because group therapy has a powerful impact, especially at first.  Connecting with other hair pullers helps people realize on a core level that they are not alone, that they are not “freaks” and that some pretty amazing people have trich, hence they may not be all that horrible.  People with trich tend to be smart, caring, successful, unique people and that is the honest truth, so being in group is an incredible shame-reducer.  Once people realize that this group of amazing others also has trich and also cannot stop the behavior, their ability to accept themselves, let go of shame and stop blaming themselves for the disorder is improved exponentially.

However, because of my belief that certain underlying intra-psychic issues must be identified and addressed, I find that the most successful way to go is to work with people individually on those issues, and then move to group therapy.

Group therapy addresses interpersonal issues (issues one has in relating to others) while individual therapy addresses intra-psychic issues (issues relating to the internal psychological processes of the individual).  I find that groups are much more effective and fruitful when people have had been involved individual therapy.


When a person is pulling, what is their body trying to tell them if not that they are in physical discomfort?

It would be their body and their psyche trying to inform them of the following:  1) A need for rest, food, comfort or a break 2) They are ignoring their feelings. 3) That they are resentful about having said yes to a favor or a request  4) That they are unhappy in some circumstance of their life and believe they can do nothing about it (job, relationship, issues with their kids).  5) Ignoring their inner voice about what they really want or need in life, either short-term or long.

To go into detail: Pulling is often a response to a need for rest, food and comfort.  When hair pullers refuse to take breaks, refuse to schedule time for themselves, and believe that to take time for themselves means they are “selfish and lazy,” then generally the urge to pull will force them to take some kind of time to themselves, even if via pulling. Pulling can also be response to repressed feelings, since feelings must be felt.

One thing you see often in hair pullers is a person who has a lot of judgments about feelings.  If they feel sad but believe they “should not” feel that way because the circumstances don’t justify it, they will ignore or deny the feeling. They might believe allowing themselves to feel is “self-indulgent” and that once they open that Pandora’s box they will have no control over themselves.  Of course the feeling just never goes away if one doesn’t feel it and allow it, but rather sits beneath the surface at all times.

Hair pullers are notorious for saying yes to favors or requests from their friends, neighbors, spouse, children, boss, when they are exhausted and depleted because they are so used to ignoring how they feel and what they need.  If they hate their job, for example, most hair pullers believe they have no right to try to find another or figure out what they really want to do because they believe it’s selfish to concern themselves with personal fulfillment or that they should be “grateful” for having a job at all.  That thinking misses the real point.  It isn’t that they should start complaining, but that they have to take it seriously if they seriously dislike the portion of their life between 9 and 5 every day.

If you have trich, hair pulling may be the only way your inner voice can attempt to be heard.  Again, hair pullers are typically quite dismissive of that inner voice.  They may know how every single person in the room feels, what they need, whether they are happy but they don’t know those things about themselves.  Until they do,  recovery will be delayed.


What are some behaviors that you recommend to replace the pulling with? 

I don’t actually recommend replacing hair pulling with another behavior because, in my opinion, hair pulling is not about keeping one’s hands busy but absolutely about the effect hair pulling has on the psyche and mind.

The repetitive motion of pulling creates a trance-like altered state and it’s this altered state that pullers are after. It would be like my suggesting to an alcoholic that since he is used to drinking bourbon on the rocks, why not drink root beer on the rocks as a substitute? That way he can hold a glass, rattle the ice in the glass and sip on a liquid. Now we all know that’s ridiculous because alcoholics aren’t addicted to alcohol because of the liquid in the glass; they’re addicted to the effects of alcohol.

The real “substitute” for hair pulling is to shift into a different relationship with one’s self, one in which you support and accept yourself. I recommend the book “Radical Acceptance” by Tara Brach to every hair puller and skin picker I work with. This book will guide one through the process of making that shift.

Another thing I recommend is not going from working and ‘doing’ to sleep or rest suddenly. Transitions like falling asleep and awakening are often dangerous times for hair pullers. Learning to wind down after a busy day before sitting or lying down to read or watch TV is extremely important. One can do something like: 10 minutes of evening yoga (many 10 minute yoga relaxation workouts one can download or watch on DVD); a relaxation or visualization exercise (using a recording is easiest). If you’ve been going all day, help your body turn its motor down before you plop down to read, get on social media or watch TV. Otherwise your body will rely on pulling to do it for you.


What else would you like to share?  Please feel free to add more – your work is very meaningful and I’d appreciate anything you have to say.

One last thing; It’s very important for hair pullers and skin pickers to remember that there is some unreliable info out there on the Internet, especially because people are far, far more likely to use the Internet to complain, to say things like ‘it’s impossible to recover from Trich’ (which is untrue) than they are to get on the Internet to say, “My hair pulling is decreasing rapidly” or, “I no longer pull.”

There is no question that one can recover from Trich and CSP, I see it every day, however recovery is gradual and requires working on issues like self acceptance and codependence.

I find that AA or other 12 Step Groups, specifically, open meetings (open to non-alcoholics), as well as CODA (codependents anonymous) can be enormously helpful for hair pullers and skin pickers. So can classes on mindfulness, meditation and yoga.

Any opportunity to be present with yourself like that, combined with connecting with other hair pullers (online or in person), and/or psychotherapy; these things are all enormously helpful on the path to recovery.

Thank you for allowing me to share my perspective on Trichotillomania and Dermatillomania. These disorders are not weird, bizarre or disgusting. They add decidedly human. The more we talk about it the less “weird” it will start to seem.

“I am human. I consider nothing human alien to me.” ~Roman Playwright Terence (circa 170 B.C.)

To reach Claudia Miles, LMFT:

Email: ClaudiaMilesMFT(at)
Office: 437 S. Robertson, Beverly Hills‎, CA  90211
Tel: 415-460-9737
Twitter: @Trich_Recovery

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