Case 1: "Mrs. R___," I began, "Your daughter Marcie (nine years old) just isn't making the progress in her therapy that we had hoped she would. She hasn't been doing her homework, and it just seems that her heart isn't in it. I think she's just going through the motions, and is only coming here because she doesn't want you to get upset with her. This really doesn't seem important to her at this time. I think the best thing would be for us to take a break for now. Marcie's mother agreed. "Whenever I ask, she says she isn't pulling, but I have actually seen her doing it a few times lately. When I ask her about it, she totally denies everything, but I can see for myself that nothing is growing back."
Case 2: "My fourteen year-old daughter pulls her hair," said the woman on the other end of the phone. "I want to bring her in for treatment, but she doesn't seem to care about it. Part of the hair on the top of her head is missing, and so are her eyelashes, but when I talk to her about going for help to do something about it, she says it doesn't really matter and that she doesn't care. She says it's just a bad habit, it isn't that bad, and that she really can control it. If I try harder to get her to talk about it, she just gets angry and storms out of the room. Is there some way we can make her care about it and go for help? Doesn't it bother her that she looks this way?"
The two case scenarios above are typical of children who are not prepared to begin working on a recovery from their trichotillomania (or compulsive hair pulling, as it is also known). I have encountered situations like these quite a number of times over the years. Our first case depicts a child who is simply too young, and our second shows an adolescent who has not yet accepted that she has a problem. One of my old college professors once told me "You can sum up most of child psychology in one word readiness." Neither child is ready.
There is a percentage of younger children who have pulled out head hair, eyebrows, or eyelashes who appear indifferent to what they have done. If asked, they will acknowledge that they have pulled out the hair, and even acknowledge that it looks unsightly. What they may not show is concern or distress over the fact. This can be extremely perplexing to parents, who ask, "Why doesn't it bother my child? Can't she (or he) see how bad it makes them look?" Parents also worry about whether or not their child will be teased or ostracized as being "different" by the other children, or else regarded as some kind of "freak."
The answers to these questions are not very mysterious. Preadolescents frequently seem untroubled by their altered appearance, even if eyebrows are missing, eyelashes are gone, or patches of hair are missing from their heads. When this occurs it is most likely due to a lack of social maturity and awareness on their part. They haven't yet become conscious of their appearance or the notion of "fitting in" socially. As long as their behavior doesn't immediately interfere with school or play activities, it is of no importance to them. Their playmates may not be that conscious of it either, or may take notice of it, but not really care. Where younger children do seem extremely bothered by their lack of hair, it is either because they are socially precocious, or they are reflecting their parent's distress over the problem. That is, they are upset because their parents are upset, but not because it is upsetting to them directly.
When some younger children are brought for treatment, as in our first case scenario, they tend to be generally unmotivated and uninterested. Their reaction is that this time could be better spent playing, watching TV, or getting their schoolwork done. Getting impatient or angry at them is really useless. Trying to change a child's behavior in this way will only create more stress, and one of the reasons people pull, of course, is to relieve stress. A child may also react to this pressure by being more secretive about their pulling, denying that they are doing it, or by pulling more to express frustration and anger at their parent's behavior. You wouldn't get angry at a young child who wasn't ready to be toilet trained yet (or at least I hope not). Children do things when they are ready, not when we are ready for them to do them. Even if they are ready, at any given moment, they don't have to want what we want. A parent may not like this fact, but they may have to accept it as something they have no control over.
If parents truly want to be helpful, and avoid creating paradoxical situations, they have to work on controlling their own upsets in cases like this. Sometimes the message that gets communicated is not "I don't like your behavior," but instead, "I don't like you as much as I used to because of the way you look." More than anything else, children want our unconditional love. If they feel that they cannot get this, they can react angrily, trying to get us to change. The result may be the pulling of even more hair, just to send a message. There are things our children do that we simply cannot control, and when it comes to certain things, they hold the trump card.
Of course, no one likes to have a child who is different, or who doesn't look or act like other people's children. You don't ever have to like it. Acceptance doesn't mean liking something. It simply means acknowledging the reality of things as they are and what can be done. Accepting is not something that you just get through all at once. It is something that you will have to work on every day. It may also help to try to put things in perspective. This is the child you love, with or without hair. He or she is still who they were before they began pulling, and still has feelings, too. There are many worse things that can happen to your child, many of them untreatable. Having this problem doesn't make them any less of a person, and it is something that they can recover from, even though it may not be right now.
In the case of our teenager in Case 2, it is not unusual for someone of this age to not want to admit to a problem that they know full well exists. Unlike preadolescents, many teenagers are extremely self-conscious, and very sensitive about their image, as they are still trying to figure out who they are. They tend to examine themselves under a microscope a lot of the time. A teenager's angry or sullen denial of a problem such as in our case is admittedly not a very good way of dealing with things, but to someone who is still not fully mature (even if they have an adult-sized body) it may be the only way they can cope and preserve some kind of positive self-image. The harder a parent pushes, the angrier the teen's response may become. The strength of their denial will also increase, as may their pulling.
So what can parents and therapists do when a child or adolescent seems disinterested or unmotivated? As a therapist, I do not jump directly into treatment. I like to make a careful assessment of the symptoms, the situation, the person, and what that person brings or doesn't bring with them to therapy. I am very careful in the first session to find out whose idea it was to come for help. I will typically ask a child or adolescent, "Whose idea was it to come here today?" I routinely follow this up with "Do you really want to be here?" When faced with someone who is not very unenthusiastic about treatment, and who would rather not be there, I have a policy I have evolved over the years. It applies whether the reluctant sufferer is at their first session, or at their tenth. My overall guiding philosophy here, is that you cannot want someone to get better more than they do. I would rather leave someone with a good feeling about having seen a therapist, than make everything connected with the experience unpleasant. If we have at least been able to accomplish this much, then we have still achieved something important.
I tell disinterested or reluctant children and adolescents:
"It's really okay if you don't want to do this right now. I don't want you to feel so uncomfortable that you have to not tell the truth or make excuses to avoid coming here. I only want you to come here to work with me if this is truly where you want to be. I won't be mad at you, and actually, I really appreciate your being honest with me. Maybe some day in the future, you will want to do something about this problem, and if you do, I will always be glad to work with you. So why don't we take a break. You can go home and think about what you would like to do. Here is my card. You can keep it or give it to your Mom or Dad. All you have to do is call me or have them call me any time if you would like to come back. Even if you decide to come back a year from now, I will still be happy to help you." I also tell them "Don't worry about what your Mom or Dad will say, either. I will talk to them and explain the way things are. I will tell them to leave it up to you, and to trust that you will know when the time is right. I will ask them to not mention your hair to you, until you want to talk about it."
In this way, we can part on good terms, not having created some kind of senseless test of wills that the parents and I cannot possibly win. We have left the door open, and put the responsibility and sense of control in the hands of the person with the problem. I have had a number of children, who when left to face their situation themselves, have later returned to successfully work on recovering from their hair pulling.
I am a great believer in encouraging the development of personal responsibility in both my child and adult patients. The well-known psychologist Rollo May once said "People only change when it becomes too dangerous to stay the way they are." Only the sufferer can tell when they have reached this point. Once there, they must be relied upon to do what must be done, if it is ever going to happen. Even if we could stay on top of a child or adolescent and force them to go through the motions and follow treatment instructions, they will have learned nothing. As soon as they are out from under a parent's watchful eye, they will quickly let it all go. My advice to parents is that sometimes doing nothing is really doing something. Don't nag, pressure, annoy, criticize, threaten, yell at, or punish your child for not wanting to participate in treatment. Threatening them or taking away privileges will only create more resentment and resistance, lead to more pulling, and will finally put the entire subject of hair pulling beyond discussion of any kind. When your child finally comes to you and says "Mom and Dad, I need some help," they have finally gotten to where you want them to be. They are ready. Something positive can now happen.
Whose hair is it, anyway?
If you would like to read more about what Dr. Penzel has to say about Trichotillomania, take a look at his self-help book, "The Hair-Pulling Problem: A Complete Guide to Trichotillomania," (Oxford University Press, 2003). You can learn more about it at www.trichbook.com