Identifying the Primary Goal of Trichotillomania Treatment

Spotlight Article with Claudia Miles, LMFT

Identifying the Primary Goal of Trichotillomania Treatment



Claudia Miles, LMFT specializes in compulsive hair pulling & 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.


When dealing with a TTM what is the primary goal?  Is it to be “pull free” or is it something else? 

That depends upon the person.

Most people come in and want to be pull-free or pick-free of course, and that is certainly attainable, but the only way it’s going to happen is to do the psychological work underneath.

If you are asking me what is recovery, I can tell you that it is FAR BEYOND a cessation of the behavior.  It is a state of mind.  Unless a person has been able to let go of the shame they feel about the behavior (or the missing hair or the scarred skin), they are not in recovery, in my opinion.

Step one is to work on letting go of that shame and letting go of the judgments. Trich is one of those conditions that FEELS like a voluntary behavior, but simply is not.  The urge to pull is so strong, and the behavior can be so unconscious, it is absolutely not controllable.  No matter what people who do not have it think, that is a fact. These urges are beyond powerful.

Imagine for instance if your body itched like crazy all over, all day long.  Could you commit to never scratching?  Ever? No you could not. The moment your attention was diverted you would be scratching.  This is what’s like to have trich. Resisting this urge without doing some of this other work is pretty much impossible.  In fact, RESISTING does not work.  One has to become a kind of Aikido master and learn how to turn the urge back onto itself.

Also, people with trich and derm share many of the same personality traits and defenses which need to be addressed.  These traits include:

  • perfectionism (a need for what you do to be “perfect” to hide the internal sense of not being good enough)
  • co-dependence (a focus on what other people think, on pleasing others, on living life based on what others may think, a need for external validation to feel OK about one’s self)
  • difficulty saying no to things because they are overloaded
  • a belief that if they aren’t accomplishing things every moment of the day they have failed
  • a focus on the “to-do” list at the expense of all the other aspects of being human

This list goes on of course.

It is 100% true that people will come in because they say they want to stop pulling and when they leave, they may well be completely or nearly completely pull-free, however what they say to me is that the other changes in their life are what they are truly grateful for.   That more important than the cessation in pulling are the changes in their life as a whole.  No one leaves without telling me that.

As for pull-free, well I’ve had clients who pull six hours straight every day and for one, when she left, she pulled 6 MINUTES a day max. That was acceptable to her and she had made all these other changes.  Recovery is always going to be gradual. And the key to recovery is to be able to “tolerate” having one bad day out of the blue, maybe after many good days in a row, and not allow that to define you or to mean that you have “failed”.  To not realize that it doesn’t mean  that you will “never be able to stop pulling.”

Recovery is what is acceptable to the client  and there needs to be some internal shift that occurs for a client to start to see what they really want.  If someone stops pulling 100% but feels like they will “die” if they ever pull again, that, to me, is not recovery.


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