We are honored to share this piece by Ellen Crupi, the Director of Awareness at HabitAware and a "Trichster" of 40+ years. Ellen tells us about growing-up with the recurrent and irresistible urge to pull at her hair.  

Ellen interviewed Dorin Azerad, a hair-puller and hairstylist, for suggestions on ways to start the conversation with a client you suspect is pulling their hair and how to proceed from there.

We've also included a TedTalk by Aneela Idnani, a mental health advocate, co-founder and president of HabitAware, who is on a mission to raise awareness around Body Focused Repetitive Behavior (BFRB), a family of conditions that include compulsive hair pulling (trichotillomania), skin picking (dermatillomania) and nail biting (onychophagia). These are the most common mental health disorders you've never heard of, with approximately 1 in 20 Americans affected. 

These women are building awareness for an often-misunderstood condition.  Please know that they are offering-up intimate details of their own struggles because they are working to remove the stigma around Trichotillomania while also helping stylists recognize the disorder.  

As Dorin says, “Once you understand the problem, you will become an asset and resource to your client.”

Ellen Crupi, the Director of Awareness at HabitAware

“Sandy, there is something wrong with Ellen.” 

My mother walked over to take a closer look as Fatima pointed her comb at the back of my head and said, “Look, there are two bald spots behind her ears.” 

 “What did you do!? What’s wrong with you!?”  Both women asked me.  

“Anne put gum in my hair and I had to pull it out.”  I lied.  There was no gum.  But I was pulling out my hair.  

I was barely 11 years old that day in the hair salon.   

Why do I pull out my hair?  It felt so weird and alone.  I wanted to stop. I tried to stop.  But stopping was impossible as my hands had a mind of their own.  I began to dread haircuts.  Each time I sat in a stylist's chair watching as they combed through my hair, the same running dialogue raced through my mind.

Did I cause any visible damage?  Will they see any thinning or bald spots?  Should I say anything?  Will they say anything?  

No one said anything.  Six years after Fatima pointed out my bald spots, I gathered up what little self-confidence I had and confessed my hair-pulling secret.  Maybe this time Fatima could help? Her advice:  If you are going to pull, pull the hair in the front of your head as you have too much hair there anyway.  

I don’t have to tell you, that wasn’t good advice.  But what it did teach me was to keep my hair pulling secret, a secret.  

Six-months later on the blackboard of my college Abnormal Psychology class was a word I did not know.  But that word knew me.  It was Trichotillomania.

What is Trich-o-til-lo-ma-ni-a?

Trichotillomania (pronounced trik-o-till-o-MAY-nee-uh), also referred to as “hair-pulling disorder,” is a mental disorder that involves recurrent, irresistible urges to pull hair from the scalp, eyebrows, eyelids, and other areas of the body, despite repeated attempts to stop or decrease hair pulling. 

According to the TLC Foundation for Body-Focused Repetitive Behaviors, 1 in 20 have trichotillomania.  Trichotillomania is a self-soothing coping mechanism for anxiety, stress and even boredom.  Trichotillomania usually presents in early adolescence coinciding with puberty and affects more girls than boys.  

No one knows exactly what causes trichotillomania, but there is evidence it is partially a genetic disorder.  Most pull their hair out without awareness while doing other activities such as reading, driving, or watching TV.  While hair pulling sounds like it would be painful, many with Trichotillomania report that it feels good, which is one reason why it’s so hard to stop the behavior.  Others describe the sensation similar to scratching an itch, providing relief.  Even though some might feel pain with pulling, Trichotillomania is not self-harm.  

Hair pulling varies in severity and can result in thinning hair, bald spots, loss of eyelashes or eyebrows, and even total baldness.  It’s not possible to identify trichotillomania simply based on the appearance of a bald spot or thinning hair.  Bald spots caused by alopecia, for example, can look very similar and may come and go as either disorder goes in and out of remission.  

Many with trichotillomania live with intense shame and guilt, often hiding their disorder from friends and family because they are afraid of judgement and lack of support. 

Everyone’s Trichotillomania journey is different.  In looking back over mine, I varied from mild to moderate over the course of 40 years.  I had wavy, curly hair where I could typically hide my damage, though not always.  I learned to pull all over to reduce the likelihood of unevenness and bald spots, though that didn’t always happen.  

The internal shame and guilt of being unable to control my behavior robbed me of self-confidence and replaced it with dread.  Every single day I was constantly checking.  Did I pull to much?  Did I clean up the evidence?  Did anyone notice me pulling?  And the always present:  What’s wrong with me?  Why can’t I stop?

While there is no cure for trichotillomania, some “trichsters” respond well to cognitive behavior therapy (CBT) and habit reversal training (HRT).  I tried it all:  hypnosis, acupuncture, medications, supplements, individual and group therapy.  While group therapy did give me some relief, it didn’t stick.  It was the lack of awareness that tripped me up every time.

All that changed in May 2017.  After a 3-hour pulling session while watching TV, I googled “breakthroughs in Trichotillomania” and an ad for HabitAware’s Keen bracelet appeared. The bracelet was invented by someone who grew up with this issue.  The bracelet uses real-time gesture detection technology to make you aware of where your hands are so you can be empowered to make healthier choices.  

Keen gave me the awareness I needed.  When my hands would find their way to my head and begin searching, Keen’s gentle vibration, like a hug on my wrist, made me aware.  Once aware I had a choice, to pull or replace my unwanted behavior with healthier behaviors.  

Within months my shame and silence was replaced with being loud and proud.  

Being a Resource

Dorin Azerad, hairstylist and fellow “trichster”

As cosmetologists, you are more than a stylist. You are a first line of defense, and you might even find yourself acting as a therapist would.   Client’s will often share their daily frustrations and intimate secrets while sitting in your chair.  But a client living with trichotillomania will likely hide it from you, and might skip coming to the salon altogether.  

Once you understand the problem, you will become an asset and resource to your client.

The first step for a hairstylist is to create a judgement-free zone.   

What a trichotillomania client is looking for most in a hair stylist is for your chair to be a safe space. Every Trichotillomania client is on their own Trich journey and you have to meet your clients where they are.  

Dorin Azerad, hairstylist and fellow “trichster” suggests this simple yet effective conversation starter: 

”How are things going with your hair?”  This is a powerful yet gentle question.  This warm starter stems from genuine curiosity and allows your client to open up or choose to wait, without sensing any judgement.  

The second step is education.  Make sure to have information about trichotillomania available for clients and for stylists.  Contact HabitAware and The TLC Foundation and ask for free brochures. This serves two purposes.  When your client is ready to open up, you are ready with resources to share.  Plus you can have the brochures available in the waiting area for clients to take on their own.  

Wigs, toppers and hair fibers (e.g. Toppik) are great options for clients with hair loss from trichotillomania who are looking to cover up or disguise bald or thin spots. While traditional hair extensions can help camouflage any thinness, they may not be the best option for trichotillomania clients as they can cause discomfort and also can be pulled out easily. 

Do’s 

• Allow time to build trust with your client

• Be sensitive and compassionate.  Listen without judgement

• Wait for your client to open up to you

• Minimize the people involved in the styling process  

• Have brochures at stylists stations and waiting areas

Don’t 

• Don’t ask about or call attention to the hair loss

• Don’t advise your client to “just stop pulling”

• Don’t assume someone's hair loss is from compulsive hair pulling 

Here are a list of resources to share with clients and salon staff:

• TLC Foundation for BFRBs  - for education and a list of therapists, support groups, directory of hairstylists, all who are trained in serving those with Trichotillomania

• HabitAware

• HabitAware’s blog 

• Dorin Azerad Trichotillomania Hair Stylists

When you have a trich client in your chair, the best thing you can do is create a safe space where the burden of your client’s hair and hair loss is no longer solely in their hands. As their hairstylist, you’re taking care of their hair, if only for the length of the service.  

About Ellen Crupi:

Ellen is the Director of Awareness at HabitAware and a fellow "Trichster" of 40+ years.  Ellen is eager to help others find positive change with Keen & she is passionate about healthy living, exercise and dark chocolate.  ellen@habitaware.com

About Dorin Azerad: (@dorinazerad)

Dorin is a hair-puller and hairstylist - the trichotillomania hairstylist.  She has been living every day of the past 20 years with trichotillomania.  Dorin is your biggest cheerleader on your trichy journey. dorin@dorinazerad.com