Author: rezendevknowfully.com

Don Clark on Psychotherapy with Gay Clients

Posted on by rezendevknowfully.com
Ruth Wetherford: Don, thank you for letting me interview you today for Psychotherapy.net. I’m so pleased.
Don Clark: Well, I am delighted to be your interviewee.
RW: Thank you. Let's start with a brief introduction for those who don't know you, or who have not read Loving Someone Gay, You say on your website that this book is so associated with you it's practically part of your name.
DC: Yes.
RW: What would be a general outline that would orient people to your work?
DC: That would be the book Someone Gay: Memoirs that I wrote, which is about 350 pages long. But I assume what you want is a thumbnail sketch of what my life as a therapist has been like?
RW: Yes, but first give us an introduction from before you became a therapist. You describe in Memoirs being born in 1930, during the Great Depression, which influenced you strongly, because though you grew up in New Jersey in relative poverty, you still had opportunities that gave you your strong desire for education and your love of learning, which has guided you all your life.
DC: It wasn't relative poverty. It was poverty. As in, we moved frequently because we couldn't pay the rent. And my parents really were basically illiterate. My father could not read or write. My mother was able to do some reading and she was the writer. My father's writing was limited to signing his name to things, which he did very meticulously. But there were fortuitous events. Perhaps everyone has them, I don't know. Like when I was in the eighth grade, I hated school, because of course being socially at the bottom of the totem pole you get picked on by other kids. Recess was a nightmare.

But in the eighth grade, bless her heart, my teacher must have seen something, and pulled me from the back row up to the front row of the class, and started smiling at me. And I don't remember a teacher ever having done that before. So I started paying attention to her. And her passion seemed to be diagramming sentences in English. Instantly I became the best diagrammer of sentences in the class. Since that had to do with words, which I had been playing with all by myself unbeknownst to other people-trying to decipher Shakespeare, for instance, which I had decided was a secret code like the ones being used by the Allies and the Nazis. I was already enamored with words, and I had already tried writing poetry, but all of this was unknown to any teacher. So we were in this together, now, the teacher and I. We were doing words. And I became her darling and she became my darling, and when it came time to do the eighth-grade yearbook, she appointed me chairman of the committee. I ended up writing the whole yearbook, and I did it in poetry!
RW: That illustrates the power that an individual can have in a child’s life.
DC: Oh, god, teachers, absolutely.
That one teacher in eighth grade saved my life, I'm sure. I would have been working in a factory like my siblings.
That one teacher in eighth grade saved my life, I'm sure. I would have been working in a factory like my siblings.
RW: How did you come into psychology?
DC: Well, I always had to work, of course. Money was always needed in the family. And so one of the jobs I took when I was in high school was an usher in the fanciest movie theater in town. In the beginning I was only allowed to work days, but when I became sixteen I was able to work evenings. And I remember one of the first evening programs I saw was Spellbound with Gregory Peck and Ingrid Bergman. Of course, I fell in love with both of them immediately. I fell in love with a lot of movie stars during that period, male and female. And the males were silent; the females I could talk about. And I wanted to be just like her. She was a psychologist, interestingly. She was acting as a psychoanalyst in the film, but she was called a psychologist. So, duly noted, I thought I would be a psychologist, so that I can save young handsome men like Gregory Peck who have had these awful things happen to them that they can't remember, but I'll help them remember and they will be cured.

So when I got to college, at Antioch in Yellow Springs, Ohio, I started out as a business major, then I became an art major. Then, I took a couple of hospital jobs in the Antioch work-study program. The first one was hideous. The second one was wonderful, at Chestnut Lodge, which was the mental hospital in Maryland that Harry Stack Sullivan had been the control analyst in when he did his writing, and he was followed by Frieda Fromm-Reichmann, who was still there at the time. I had a chance encounter with one patient who had been mute for years. I was nineteen or twenty years old at the time. For whatever reasons, I think she fell in love with me, and I was able to get her to talk and to move and to ambulate, to the point where I was able to take her on a train trip to visit her mother in New York City, which everyone considered to be a total miracle. Frieda Fromm-Reichmann offered me an analysis at fifteen dollars an hour, which of course I could ill afford, but I understood it was a bargain, if I would stay and work with this patient, which I was delighted to do. By the way, Morrie Schwartz–the sociologist at Harvard, who became known for Tuesdays with Morrie– got fascinated by it and he recorded a meeting with me every week a about this. Everybody was trying to figure out why it was working, how this was happening. Now I know why it was working, but then I didn't.
RW: Why do you think it was working?
DC: I really cared about what she had to say, and I cared about her. She had not had that before. Even in her analysis there, her presumed analysis, which was a joke since she was totally mute, no one was giving her any warmth. So the first time we met was when she raised herself up off the floor and threw herself at me, literally, and I caught her in mid-air. Her legs were wrapped around my waist, her arms were wrapped around my neck, she was grunting and salivating, and she was kind of a mess. But I said, like a well-trained twenty-year-old on the staff, I said, “Mary, I think you’re trying to tell me something.”
RW: But you did it with kindness.
DC: I cared about her, and I came back at night on my own time when I was off duty to sit with her and draw little boxes and ask her questions and say, “If the answer to this is yes, just put a mark here. If it’s no, put a mark there.” I’m laughing and almost on the verge of tears, because it sort of reminds me of Ann Sullivan with Helen Keller. No one had taken the trouble to do this with her. And I wouldn’t have either, had it not been that she had thrown herself at me.
RW: Right.
DC: I guess that makes me a sucker for people who throw themselves at me.

The Importance of Empathy

RW: You’re talking about the role of empathy.
DC: Yes.
RW: As a key ingredient in what makes psychotherapy work.
DC: Empathy and warmth. Showing that you really care.
RW: Showing it. And feeling it.
DC: Yes.
RW: How long have you been a psychologist? Half a century? When would you say empathy emerged as something that psychologists talk about as a key ingredient?
DC: God, I don’t know. I mean, in a way, in the writings of Harry Stack Sullivan you see some of it because, as far as I know, he was the first person saying, “Look, there are two people in the room. And it’s not just this cold analytic idea about the patient, and you sit behind the patient with a pad and paper and write things down. There are two of you there. There’s an interaction going on between the two of you. Pay attention to it. Pay attention to what you’re feeling, pay attention to what the patient is feeling, and to what the interaction is between you. Be real.”
RW: Right, like Carl Rogers.
DC: Yes! Carl Rogers, absolutely.
RW: Who else has influenced your work?
DC: Well, in terms of the analytic school, that was it,Stack Sullivan, Frieda Fromm-Reichmann. Gosh, Carl Rogers played a big part. I was already very interested in what he was doing while I was an undergraduate student. I remember going to the library, I think he had one book published so far, and everybody was making fun of him…
RW: Do you want to say anything about your mixed feelings about Fritz Perls?
DC: Oh, I spent some time at Esalen in its heyday in the early '70s, when I was on a Carnegie grant mission studying the new human potential movement. I really paid attention to what the Esalen staff were doing. I was permitted into the royal presence of Fritz Perls, who was the reigning diva there at the time. And of all the people I studied on my Carnegie sabbatical from university teaching, he put more fear into me about what was being done with all these new things than anybody else. I named in my report Marion Saltman, who was a woman who did play therapy with adults on a houseboat in Sausalito, as the person guaranteed to do no harm, and often did a lot of good. I named Fritz Perls as the person who was most likely to do harm while sometimes doing a lot of good. He was very good at what he did and very smug.
He was like a surgeon who went into the operating room, did everything exactly right, laid the guts out on the table, and then smiled at the young residents and said, "Okay, you take over now," and pulled off his scrubs and left.
He was like a surgeon who went into the operating room, did everything exactly right, laid the guts out on the table, and then smiled at the young residents and said, "Okay, you take over now," and pulled off his scrubs and left. And I witnessed one, and know about another one, where following his dramatic interventions, the people went into psychotic episodes. Now, I'm sure he rationalized that as saying, "Well, that was what they needed to do." One of them was the wife of a colleague in the university where I taught. I don't think that's what she needed to do. And it brought a lot of grief into that family for both of them. So, I have mixed feelings about his diva behavior.
RW: Well, it sounds like it wasn’t compatible with the importance of empathy.
DC: Right.

Early Struggles for Gay Rights

RW: Going back to the work you're best known for, Loving Someone Gay, you talk a lot about the importance for gays of being visible and resisting discrimination in any interaction that you have energy to deal with. If you hear a slur, if there's legislation, if there's something in writing, etc. I believe this is important for a gay person to become able to do. This is something you did in your efforts toward depathologizing homosexuality within professional psychology. What were some of your activities toward that?
DC: Oh, boy. Well, the roots of this are back at Antioch when I was an undergraduate there, because it was, and apparently is going to be again, a very social activist school. I think within the first weeks that I was there as a naive eighteen-year-old freshman from New Jersey, we were picketing the barbershop in downtown Yellow Springs, Ohio, population 2,000, because the one barber in town would not cut black people's hair, saying he did not know how, because they have different hair. Well, that was just a small example. Actively advocating for disempowered people permeated the school, and during the time that I was there, people took it really, really seriously. So, going back to Mary, the woman at Chestnut Lodge, perhaps I wouldn't have been smart enough to do what I did.
RW: If you hadn’t had the Antioch experience.
DC: If I had not already been immersed in that very well.
RW: So you were primed for this struggle. Because Stonewall* was in the summer of ’69.
DC: June '69. But I was already rolling before that.

Coming Out as a Gay Psychologist

RW: Yes. So how did you address professional psychology about this?
DC: Oh, god. I think I started writing letters to the editor. I know I wrote a letter to the editor of Time magazine, when they did a big expose about gay people, and my father-in-law at the time was devoted to Time magazine. And I was beginning to get it, that if I said, "Hey, I'm the expert in this field because I am gay," that's where I was going, that's what was beginning to happen, other therapists backed off. They had no credentials. But Time magazine, lo and behold they printed my letter as the lead letter two issues later. My father-in-law called my wife and said, "Hey, Don's letter is the lead letter in Time magazine this week. I don't know what he's talking about, but isn't that great?" And I wrote letters to the APA (American Psychological Association) too. I was beginning to get in touch with other gay therapists, mostly not out yet, but it was happening. The groundswell was beginning to happen, when I moved back to California, in January, 1971.
RW: Being gay was still officially a mental illness.
DC: Oh, absolutely. Absolutely. And I could lose my license. I had a license in California, one in New York, and I could lose them in both places for “moral turpitude.”
RW: If you were homosexual…
DC: Guaranteed, if you’re homosexual, because the law describes homosexuality as criminal, the church describes it as sinful, and psychology describes it as a mental illness, you’re going to be tossed out because it’s moral turpitude.
RW: Well, when I was taking abnormal psychology in graduate school in 1971, it was still in the DSM-II as a mental illness, right between alcoholism and personality disorder. How did it get taken out of the DSM, and what was your role in that?
DC: I think the first public appearance about it, per se, was here in San Francisco at a Western States Psychology conference, and I was the new kid in town, but the word got around fast, I had come out, and I had left the university and come to San Francisco specifically because I had decided to start a full-time private practice devoted to gay people.
RW: Were you the first in San Francisco?
DC: Absolutely. Or anywhere.
I was the first one to say, "I'm gay. I'm devoting my practice to helping gay people, their families, and their friends in any way I can."
I was the first one to say, "I'm gay. I'm devoting my practice to helping gay people, their families, and their friends in any way I can."
RW: You were full of moral turpitude.
DC: I certainly was. So at the Western States meeting, there were four of us presenting on a panel on homosexuality, organized by John Neumeyer. I think all of us were gay, but I was the only one that was going to say it. I didn’t know I was going to say it actually, until I got up, and as I stood in front of the microphone, before I had said anything, I looked at the audience, and what I saw was a big room, packed with about 250 people who were very interested in what homosexual people might be like.
RW: Wow, big room.
DC: Well attended. Very well attended. I stood there, I looked, and I just opened my mouth and said what I was thinking and feeling, which is, "You know, as I look out at you people, I'm sorry to tell you, I think I see the same smug faces that I've gotten used to seeing at psychological meetings. People who either think they know all about homosexuality and have decided that it really is sick, or people who are in some way or another just beyond this. You don't even have to think about it. You can just come and be amused. Well, okay. Here's what I want you to do, for your amusement and mine. I would like every man in the audience to reach out with his right hand and put it in the crotch of the man seated nearest you."

At which point there was a standing ovation, and I think John Neumeyer nudged over close to me and said, "There are no laps out there now." But that did a lot for me. I realized if I could stand up there and call them out on their prejudice and their smugness, all I had to do was talk about what I was thinking and feeling, and people were going to listen. And they did. So from there on, I kept using my slightly false pretense in saying, "Hey, I'm the expert on this. I know about it. I'm gay." And what are you going to say to that? If a black person says, "Hey, I know about being black. I'm black," and you're white, what are you going to say?
RW: Was there any backlash against you?
DC: Yes. But I didn’t care and it truly didn’t matter. Everybody said, the friends that I interned with out here, said, “Oh my god, you’re committing professional suicide. Never mind losing your license, you’re never going to be able to have a full-time private practice. You’re going to be persona non grata.” Au contraire. I had started a little practice in Menlo Park and one here in the city, seeing which would work better. Both of them were filled immediately.
RW: Beautiful.
DC: No problem getting customers. Both of them were filled, and filled with gay people who wanted to talk to someone who would understand what they were talking about.
RW: And who would not think it was a diagnosable mental illness.
DC: Absolutely.
RW: How did it stop being that?
DC: Well, you see, as soon as a few psychologists started to be visible and probably gay, and then visible and gay, and then some more thought it might be safe to put a toe out of the closet… as soon as we started to be visible, gay psychologists’ organizations formed. All the liberation movements were happening at one time. And the time was right. People could smell it. It was going to be okay.
RW: The paradigm was changing.
DC: Yes. During that time, I joined a committee that was working with the San Francisco mental health association, or the county mental health association I think, working on this problem, trying to figure out if homosexuality might possibly be considered not a mental illness. It was amazing. From this committee, Sally Gearhart, Rick Stokes and I became the feared trio on the speaking circuit, because Sally knew the bible inside out and she would come wearing a dress or a suit and stockings and high heels. Rick was a lawyer, knew the law inside out, and he had been hospitalized for this mental illness by his parents as a youngster, and I think given shock treatment, as I recall. I was the psychologist, I was out. So all three of us were out: law, religion, psychology.
RW: It must have been around that time that the APA made the change.
DC: You know, it was actually the American Psychiatric Association.
RW: They were first.
DC: Well, because they move faster. They were just working on it at the same time. And there was actually only a thirteen-month difference between the two associations. But it looks like there’s a longer time-span because the American Psychiatric Association did it in December of 1973, and then not a month later but the following January of 1975, the American Psychological Association did it. The American Psychological Association’s change was much, much more comprehensive. The ones that lagged far behind, of course, no surprise to anybody, were the psychoanalytic people who didn’t come out for another five years, I think. But wanted to make sure they wouldn’t get shot. So then the book.
RW: Then the book. This all led up to Loving Someone Gay.
DC: I wrote it in ’75. At first, nobody would touch it with a ten-foot pole.
I got a scolding letter from the Editor in Chief of Basic Books, saying, “Doesn’t this man, he calls himself a psychologist, and doesn’t he understand these people are sick and they need help? And this is not going to help them, it’s going to help them deny their sickness.”
I got a scolding letter from the Editor in Chief of Basic Books, saying, “Doesn’t this man, he calls himself a psychologist, and doesn’t he understand these people are sick and they need help? And this is not going to help them, it’s going to help them deny their sickness.” Finally, after a year of many refusals, when Celestial Arts agreed to publish it, they sold out the initial five thousand copies before the publication date, which was January of ’77. We were really happy. But soon it collided with Anita Bryant**, so I was suddenly wanted on television and radio all over the country. Being basically an introvert, I hated the idea. But I knew… where would this kind of publicity ever come from again? So I did that. I spent about a year doing that.
RW: How many copies did the book sell?
DC: Beyond count, I mean, truly there were many printings, many different editions, in many languages. It was in two different kinds of paperbacks, mass-market editions, which was where the count got lost because nobody could figure out how many copies Bantam or New American Libraries sold. But that was why I was getting fan mail from people all over the country. Also hate mail. The ones that moved me the most were exactly, exactly the ones I wanted-the kids who had been able to sneak into a little drugstore in Podunk nowhere and get a paperback copy of this. And they suddenly knew there was another gay person somewhere out there in the world, saying, “It’s okay, it’s okay.” Now I get emails from all over the world.

Doing Psychotherapy with Gay Clients

RW: So, Don, turning now to the issue of therapy with gays, what are some of your thoughts about how psychotherapy with gay people, men and women, is different from and similar to therapy with straights?
DC: Well, we have to get into the psychodynamics of what does it mean to be gay. And, not in the interest of selling more copies of Loving Someone Gay, I really would encourage those who are interested to pick up the 5th Edition, the new one, and read it, because I can only give a few words here. The main special dynamic for a therapist to understand is that a gay person goes through a different maturational process than a straight person does. We actually go through two at the same time. We get matured through the steps as if we were straight people, and also as gay people.

The different dynamics in development of the gay childhood, young person, adolescent, and so on, is that even today, let there be no mistake, most gay people are growing up invisible. They are having to learn how to become adult as straight people do. They're also having to learn at the same time what to do with being invisible, with having nobody know who they really are, with being terrified of what would happen if they were known. Black people grow up in black families, usually. Jewish people grow up in Jewish families. Gay people do not grow up in gay families. The vast majority of the time, they do not have any support around who they are.
There is nothing comparable in the human experience. It is as if the gay child is the result of having an egg from outer space planted in the uterus of the mother
There is nothing comparable in the human experience. It is as if the gay child is the result of having an egg from outer space planted in the uterus of the mother, and then appears looking just like the people who live on this planet, and grows up, develops, but all that time something different is happening inside this person; and he or she understands early not to let it show, or not to let it show enough that he or she will get into trouble because of it. And trouble, is indeed, what awaits most of them. So, you live two lives. You hide the life of your true self.
RW: As an alien.
DC: An alien, who has these strange and different feelings about other people of the same gender, which you dare not reveal; and you learn to live as if you were having all the same feelings that your parents, and the preachers, and the teachers, and the police, etc., are having.
RW: So you’re saying that when a person discovers that they are defined by the majority as being in some way deficient or sinful or ill or illegal, that that creates a secret part of themselves, that they can’t gain approval of, and so they have to hide that. And that split between what they hold inside and what they express is part of the development that therapists must understand.
DC: And that the therapist needs to go back with them and visit through every level, every age level, every stage of that development. How has it affected them as they grew up? If they knew when they were five years old, what was like that? If they still knew when they were fifteen and were maybe even experimenting with having sex and nobody knew, what was that doing to them? How did they feel? What did that tell them about themselves? Because it affects people differently.
RW: You don’t want therapists to stereotype gays.
DC: And you always have to be on their side. It doesn’t matter how it looks to you. It matters how it looks to them. The biggest mistake is for therapists to think or say: “I’ve been studying this for years, I know what you’re thinking. I know what you’re feeling.” No, you don’t.
RW: What do you see as some of the implications of this for therapists?
DC: Well, there are a few things I put into Loving Someone Gay, aimed at everybody who wants to help gay people:
  • Number one: The gay person probably has learned to feel different. Keep that in mind.
  • Two: A gay person may have learned to distrust her or his feelings. Very important for a therapist.
  • Three: A gay person may have a higher degree of self-consciousness.
  • Four: A gay person may have decreased awareness of feelings, such as anger generated in response to a punitive environment.
  • Five: A gay person, often invisible, as such to others, is assaulted frequently with attacks on character and ability.
  • Six: A gay person is more likely to fall victim to depression.
  • Seven: A gay person may be tempted to dull the pain that surfaces, by making use and misuse of alcohol and other drugs.
  • Eight: A gay person who is respected and loved, but who is hiding his or her true gay identity and facing what she or he believes would be a ruined life, if the truth were to be discovered, is at a high risk for a fatal accident, or a seemingly inexplicable suicide.
  • And, nine: A gay person usually has lived in two worlds simultaneously.
This is why
I believe it usually is much better for gays to see a gay therapist than a straight therapist, and the therapist must never, ever hold back on revealing that they're gay.
I believe it usually is much better for gays to see a gay therapist than a straight therapist, and the therapist must never, ever hold back on revealing that they're gay. Otherwise they're acting like they're ashamed of it. They have to be able to be supportive, and the first thing that I tell young trainees is you always say something positive and affirmative when the person says anything about sexual desires, sexual fantasies, sexual whatever. If it's homosexual, you're there. You're on it, you're with it, you smile, you sit forward in your chair-
RW: Say more about why you believe gays and lesbians are better off seeing a gay or lesbian therapist.
DC: If a gay person walks into your office with a seemingly small or large problem, you may make the mistake or thinking that you can deal with it just as you would for any other person. Well, that's not true. Maybe if they just want advice on whether they should contact a lawyer because they're getting a divorce, yeah, you can deal with that just as you would with a straight person. However, if you're talking about psychodynamic issues, from day one, everything is different. They are very eagerly watching you to see if you might have any idea of what their life is like. And chances are, unless you have been through it yourself, unless you, too, were born gay and had some decent therapy yourself, so that you could explore your own internalized homophobia, which comes with the course for gay people and for not gay people.

We all have internalized homophobia because we live in a homophobic culture, which is not that unusual. Most cultures on this planet are homophobic, which is a term that was created by George Weinberg, who was a statistically oriented psychologist in New York City. He hit on exactly the right word. If you're phobic about snakes or spiders–two familiar phobias that people have–it doesn't necessarily ruin your life, but you certainly don't want to go near them, and anything that hints of them is going to make you a little uncomfortable, to the extent that for many people, with snakes for instance, seeing a picture of a snake in a book makes them consciously and/or unconsciously uncomfortable. It's just, "I'm not sure I want to go there."

Okay, so now you have a homosexually inclined client in your office, and you, as far as you know, have never had any of those feelings yourself. Or maybe you did and well, you took care of it. You're all grown up now. You've had your therapy. What are you going to do? You know, how are you going to let this person know that you really understand what he or she is feeling? My opinion, I don't think you can, unless you've been down that road yourself. And even then, unless you've had some expert help from other people like you, who have been down that road before you, who can help you to see that it really is okay to be you.
Whatever the presenting problem is, you don't go anywhere with your client unless you have that magic thing called rapport.
Whatever the presenting problem is, you don't go anywhere with your client unless you have that magic thing called rapport. And you're not going to have that rapport unless you can illustrate that you have genuine, genuine empathy. And you can't have genuine empathy if you don't know anything about the world this person came from.
RW: Well, you know there is such a big range, from low to high, of empathy or experience with gay people, within a distribution of therapists, as well as a range of how much a therapist has examined his/her own homophobia, so, it is confusing to me for you to say that you feel like gay people should only see gay therapists. Is that what you mean?
DC: Well, if I had my druthers, that would be true. I don’t think it’s possible, of course, because there are not enough gay therapists to see all the gay people who need to be helped. There is another solution. I don’t think we’re anywhere near doing it yet, but if therapists who are not themselves gay, and have not confronted their own internalized homophobia, were willing to become really, really, really familiar with the experience; to immerse themselves in it. A one-day, continuing ed course, or lots of reading about it doesn’t quite do it. It doesn’t give you the feel of what it’s like to be such a person.
RW: That is true. The subjective experiences are much more enriching to one’s understanding.
DC: So, if you’re a therapist who is not gay oriented, not gay yourself, and you want to really familiarize yourself with what it’s like to be in this world, to be one of these people, go where they go. Do what they do. Have lots of them as friends. Have lots of them in your home. Have your children be familiar with them. You know, if you’re not that comfortable, you’re not there.
RW: Well, I agree with that. But doesn’t it seem like there are other things that are very alienating besides just the fact of being gay, and having that be a secret. There are so many things about the self that are denied, cause a lot of shame, and cannot be accepted in different social circles, families, communities, cultures. And that the effective therapist knows that it’s this individual person’s experience of their situation that is important to learn, and to be open to it. And to ask the questions empathically. Isn’t that your point? Do you think it’s possible for a straight therapist to be sensitive to a gay client?
DC: I think it’s possible if you are willing to learn. That when that person sits down in your office, someone is sitting there that you have to assume you don’t understand.
RW: Like what you were saying earlier about Carl Rogers, that got him laughed at.
DC: Yeah.
RW: What advice would you have for straight therapists that you already haven’t mentioned, in working with gay clients?
DC:
Get out into the community. Get to know gay people. Get to appreciate what is better about the life they are living than the one you are living.
Get out into the community. Get to know gay people. Get to appreciate what is better about the life they are living than the one you are living. Be honest. Find out something you’re envious about. If you can’t find envy in another world, you’re not open to that world. So, maybe that’s enough about that. Get out, read about it. You know, meet people, go. Eleanor Roosevelt used to immerse herself in black culture. She didn’t sit home and read a book about it, she got out there and did it.
RW: Don, you quote Horace Mann as having a philosophy that influenced you. What was the quote?
DC: The quote, which is on the one monument that exists on Antioch’s Yellow Springs campus, is Horace Mann famously saying, “Be ashamed to die until you have won some victory for humanity.”
RW: Would you say you have fulfilled that challenge, and what is that victory?
DC: Well, I’ve tried. And I think I have. Probably through the book, since it has reached so many people and obviously done a lot of good, or they wouldn’t be writing me and telling me that. It’s certainly more of a contribution than I ever thought I was capable of making. And I’m still stunned that it happened, that I was blessed with being able to do this.
RW: Yes. Well, thank you so much for spending this time with me.
DC: Any time.

H2O Under the Bridge: A Case of Trichotillomania

Posted on by rezendevknowfully.com

The Concerned Hairdresser

"Dr. A., I'm so glad I caught you," a soft, earnest voice said. "This is Sebastian from Sebastian's Guild Salon in San Francisco."

"Do I know you?" I asked.

"No, we've never met before," Sebastian said, "but I understand you specialize in trichotillomania."

Sebastian's precise and deliberate pronunciation of the difficult word indicated perhaps a more than casual level of familiarity with the disease. "Have you been diagnosed with trichotillomania?" I asked.

"God, no!" he exclaimed, "unless you consider baldness a natural form of trichotillomania…"

"No, baldness is quite different," I said, appreciating the caller's attempt at levity.

Then, injecting a good dose of drama into every superlative, Sebastian added, "Well, if I still had my hair, the very last thing I would do is compulsively pull it out! I simply love and respect hair too much…This is not about me, Doctor, but about my dearest friend—who is also a top client of mine. She has the worst case of trichotillomania you have ever seen. I've worked with her for almost ten years now, but as creative as I am with hair—and I'm pretty good at what I do!—I've finally run out of tricks to cover up her bald spots. They're bigger than ever now, and I have less of her hair to work with, so I am officially giving up and asking for your intervention."

"Why doesn't she come in for a consultation?" I asked.

"She won't come in alone," Sebastian answered. "She needs me for moral support, she says, even though she might change her mind if she spoke to you. You seem very nice and, umm, quite friendly for a shrink. Forgive my prejudice, Doctor, but I've had some awful experiences with your profession in my day. This is not about me, so I won't go into how I was restrained against my will and given medications intramuscularly—intramuscularly!—or how I was court-ordered to get shock therapy—shock therapy! But, thankfully, all that is behind me now. H2O under the bridge…So, going back to my friend Pat, I really do think you would find me quite helpful if I came in with her. I don't know if you know this, but hairdressers are their clients' confidants, and I can give you quite a bit of important information about Pat that she may have forgotten—or that she may not even know about herself!"

Although quite worried about what I was agreeing to, and about the considerable additional baggage Sebastian was sure to add to the mix, I could not create obstacles to Pat's first visit when she seemed to be in such great need of help. "If Pat is OK with your accompanying her, I am OK with it, too," I said. "Let's all meet and go from there."

"Sounds good," Sebastian said. Then, taking on an even more theatrical air, he added, "I do have one last question, Doctor. It's for my own personal peace of mind, really. Do you think I've been enabling Pat's behavior all these years by doing such a good job covering up her bald spots? I'm so very guilt-ridden by that thought! It just breaks my heart to think I may have been part of the problem instead of being part of the solution. To think that, for years, I jokingly called her Loulou, even giving her a parrot for Christmas one year, instead of pushing her into treatment, causes me intractable insomnia. Please, Doctor, tell me that I have not contributed to my best friend's devastating problem…"

Sebastian was referring to Loulou, the world's best example of trichotillomania across species, a parrot from a French novella by Flaubert with "his front blue, and his throat golden," who displayed a "tiresome mania" of compulsively plucking his own feathers. As delivered by Sebastian, however, this obscure literary reference came across as more show-offish than cultured. His penchant for high drama, combined with his feeling of victimization by psychiatry, made for an intriguing but potentially combustible personality mix that left me both very curious and very nervous. Despite reminding myself that I would not be his doctor, I was already concerned about what role Sebastian would play in his best friend's treatment.

"I believe you wanted to help Pat the best way you knew," I said, trying to reassure him. "It's not unusual for patients with trichotillomania to go for many years before seeking professional help, and most of them don't have talented hairdressers helping them out! I doubt that Pat would have come to see me much sooner if you had not been involved all these years, though I cannot say that with complete certainty. I'm glad, however, that you have now decided to help her get psychiatric care. It's absolutely the right thing to do."

Trichotillomania: An Impulse Control Disorder

Although the usual course of trichotillomania has been well described, much is still unknown about its causes and treatments. It is estimated to affect around 1 percent of the population, with women being more at risk, although women may also be more likely to be included in the statistics because of a greater willingness to seek treatment, whether from a psychiatrist or a dermatologist.

Diagnostic Criteria for Trichotillomania:

A. Recurrent pulling out of one's hair, resulting in hair loss.

B. Increased tension immediately before pulling or when trying to resist the urge to pull.

C. Pleasure or relief while pulling and immediately following.

D. The pulling is not better explained by a skin condition or other medical or psychiatric illness.

E. The pulling causes significant distress or disability.

The overwhelming anxiety people feel before the behavior and the relief that comes with the behavior are shared by other impulse control disorders as well, including kleptomania, pathological gambling disorder, and compulsive sexuality (although the last is not formally included in the DSM-IV). In all these conditions, the pathological behavior varies, but a thrilling sensation is present, which distinguishes them from OCD, where the patient rarely derives any pleasure from the compulsion. So, whether it is the hair pulling in trichotillomania, the shoplifting in kleptomania, the betting in pathological gambling, or the repetitive cruising for sex in compulsive sexuality, these behaviors are experienced as pleasurable, although the patient is also guilt-ridden and tortured by them and is usually well aware of their negative consequences and the long-term damage they cause.

The pleasurable aspect of impulse control disorders can make them more difficult to treat than OCD, because patients are being asked to relinquish an action that, although problematic, is also enjoyable on some level. Another consequence is that patients miss these behaviors and the thrill that accompanies them when they cut back, and they may feel restless and irritable as a result. This withdrawal-like state has been likened to the physiological withdrawal from addictive substances like alcohol and is, in part, why impulse control disorders have also been referred to as behavioral addictions. In fact, Laurie, a forty-year-old nurse I treat for trichotillomania, describes the struggle to resist her pulling urges as "getting the shakes" and compares this state to what her husband, a recovering alcoholic, felt when he abruptly stopped drinking.

Another feature that distinguishes impulse control disorders from OCD is that the behaviors seen in impulse control disorders are often acted out without awareness, almost unconsciously. Laurie, for instance, would often tell me, "I didn't catch myself pulling until it was too late," or, "By the time I realized I was doing it, I had a bald spot already." Similarly, patients with impulse control disorders like kleptomania, pathological gambling disorder, or compulsive sexuality can feel so disconnected from reality and so out of touch with the risks they are running that they can momentarily justify the stealing, betting, or promiscuous behavior, minimizing what is at stake. In contrast, patients with OCD are usually very conscious of their behaviors and often keep detailed mental or written lists of the compulsions performed and the time spent performing them.

Yet similarities with OCD do exist, leading some experts to refer to impulse control disorders as obsessive-compulsive spectrum conditions. The spectrum concept has been championed by Dr. Eric Hollander, a psychiatrist and researcher at Mt. Sinai Medical Center in New York, who has detailed important parallels among these disorders. For instance, in both OCD and impulse control disorders, people experience bothersome, intrusive thoughts. In someone with OCD, the intrusive thought may be an irrational contamination fear after shaking hands with a stranger. In someone with trichotillomania, the intrusive thought may focus on how one particular hair feels different in the way it touches the forehead. Further, the intrusive thought in both OCD and impulse control disorders is usually associated with an irresistible behavior the person feels compelled to perform, such as hand-washing in OCD or hair-pulling in trichotillomania. This behavior, whether it involves ten minutes of hand-washing in OCD or pulling out a particular hair that feels different in trichotillomania, is often repetitive, stereotyped, and acted out in rigid patterns.

The First Session

Pat followed just behind. As I reflexively do when I am expecting a patient with trichotillomania, I focused on her hair first. My initial impression was that it looked artificially perfect. The immobile, meticulously arranged fringe in front and the impossibly symmetric outward flips on the sides clearly indicated that Pat was wearing a wig. As she shook my hand, I could feel the sweat and tremor in hers.

"I'm glad Sebastian called to make this appointment," she said. "I know it's overdue."

"I'm glad he did, too," I said. "I understand from my brief phone conversation with Sebastian that you have been suffering from trichotillomania for a long time."

"She has," Sebastian interjected. "Where do you want me to start?"

"Maybe we can have Pat start," I suggested.

"He knows me so well," Pat said, "and it's embarrassing for me to talk about this."

"Trichotillomania is probably more common than you think," I said, "and you're in the right place now to do something about it. We can take a break later if this becomes too much for you, but can you tell me how this problem began and how bad it has been lately?"

A long, heavy silence followed, interrupted by Sebastian's muddled outbursts as he tried to control his urge to speak on behalf of his friend. He distracted himself by rotating his rings and moving his swivel chair in semicircles.

"It would be easier for me to just take my wig off," Pat finally said, turning toward Sebastian as if to invite his help. "What you will see is worth a thousand words."

Before I could object to what seemed like an extreme gesture happening too early in our meeting, Sebastian sprang up and positioned himself behind Pat's chair, the speed and energy of the jump causing his chair to complete a full turn on its axis. Then, deftly working his palms underneath Pat's artificial locks, he squeezed both index fingers between scalp and wig, slightly loosening the wig before dramatically and quickly lifting it. Pat closed her eyes, as if she was too ashamed to face me. My eyes, too, briefly closed. I felt like I was somehow violating Pat without meaning to. Before I could establish any rapport with her, before I could offer any meaningful reassurance, an embarrassing problem that she had steadfastly kept from medical professionals for years was now abruptly revealed before the clinical gaze of a complete stranger. Something about the way it had happened felt violent, and for a sad moment, I wished I could roll back the less than five minutes of our meeting and have another chance at my first interview with Pat. But of course there can only be one first interview, and despite my regrets about the course of events, I had to make an assessment of the problem that was now being presented for my evaluation.

The natural light brown hair that Pat's wig had concealed appeared brittle and uneven. It was pulled up and collected in an anemic bun on the vertex of her head. Three one-inch bald spots on the sides were visible through the thin strands that snaked their way back from her forehead. These spots appeared red, indicating inflammation from repetitive damage to the scalp. In part to cover up the bald spots, in part to cover up the redness from inflammation, brown makeup the color of her hair had been applied to the bald areas, complicating the patchwork of color and texture. "See? That is all the hair I have left to work with," Sebastian said, as he regretfully shook his head, sounding unusually subdued and hardly desensitized to the sight. He then released Pat's bun very gently by pulling out the single needle-thin clip holding it, taking the utmost care not to lose one more precious hair in the process. Pat's natural strands fell down, showing a variety of lengths resulting from recurrent bouts of plucking.

"I have these creams I use," Pat said, opening her eyes to locate in her purse two tubes of steroid-based lotion. "My dermatologist prescribed them for me."

"Do they help?" I asked.

"Not really," Sebastian quickly answered. "And neither do all the hypoallergenic products I've prescribed," he added, stressing the "I." "We have a basket in my salon that my helpers jokingly call 'Pat's basket.' It contains a complete line of fragrance-free, dye-free, and paraben-free pomades, shampoos, and conditioners. Very expensive designer products that only our Pat gets to use."

"And what are parabens?" I asked.

"You haven't heard of parabens?" Sebastian retorted, shocked at my ignorance of a seemingly very important toxin. "It's a poison in the estrogen family," he explained. "It's been shown to cause breast cancer. It's usually found in underarm deodorants, but many commercial hair products also have it."

"I'm not familiar with the research on parabens," I said, "but I'm not surprised that all these measures have not helped Pat. They rarely do in trichotillomania, unfortunately."

"So should I stop using these creams, then?" Pat asked, pointing to the tubes in her hands. "I'm not fond of using steroids on my scalp, anyway. I heard they can cause hair loss. Just what I need!"

"Low-strength steroid creams that you apply to the skin should not cause hair loss," I said, trying to reassure her. "Dermatological interventions like these can help with the inflammation and infection that pulling can cause, but they do not deal with the fundamental cause of the problem. They address the consequences of the pulling but not the pulling itself. That is why a psychiatric approach has a much better chance of success."

"'A psychiatric approach?' I don't like the sound of that!" Pat said, looking at Sebastian as though to enlist his sympathy by reminding him of the scars the "psychiatric approach" seemed to have left him with.

"I do," was Sebastian's quick answer, delivered forcefully as he stroked the wig he had placed on his lap. "We've been in denial about this for much too long, Pat."

"How long, Pat?" I asked. "How long have you had this problem?"

Pat paused a bit as though still pondering the benefits of a psychiatric approach, then answered, "I guess it started when I was fourteen or so. Back then, I would just twirl my hair. Innocent enough, right? But then I somehow discovered the joy of pulling, and I haven't been able to stop since."

"The joy of pulling?" I repeated after her, intrigued by her choice of words.

"Yes, pulling, for me, actually feels good," Pat answered. "It calms my nerves."

"She's even used the word orgasmic once—jokingly, of course—to describe the sensation," Sebastian ventured, lowering his voice and looking away from his friend as he pronounced "orgasmic."

"Sebastian!" Pat yelled, reprimanding him for crossing a boundary she clearly did not want crossed.

"Sorry, sweetheart," Sebastian said, sounding genuinely apologetic as he reached over to squeeze Pat's hand. "We have to be completely honest with the doctor if he is to help us."

"It's an anxiety-relieving behavior, Pat," I explained, "so it doesn't surprise me that you experience it as pleasurable—most people with trichotillomania do. That is one reason trichotillomania can sometimes be challenging to treat. I will be asking you to stop a behavior that, at some level, you find soothing." Then, after a brief pause, I added, "But saying you find the behavior soothing is simplistic, of course. Even though the behavior itself feels good, you obviously don't like the consequences, and you don't like the fact that you have the disease. You wouldn't be here if you did."

"I can absolutely, unequivocally, and without reservations, tell you that I hate the fact that I have bald spots!" echoed Pat, nodding in agreement as she squeezed Sebastian's hand more tightly.

The Pleasures and Perils of Pulling

Although many people with trichotillomania pull hair from their scalps, pulling also commonly targets the eyebrows and eyelashes, as well as facial and pubic hair. In fact, the natural tendency for the disorder is to migrate over time, so that a person who started pulling hair from one site may, for reasons that are unclear but do not include running out of hair in the first site, switch to pulling from another location.

The resulting bald spots cause great embarrassment and guilt for the victim, who will often go to great lengths to hide them. Commonly used cover-up strategies include creative hair styling, wigs, excessive makeup, hats, bandanas, and false eyelashes and eyebrows. The disfigurement can lead to avoidance of social situations, dating, sexual relationships, activities like swimming and other sports, and even exposure to windy places.

Despite the Threat of Surgery

"What happened to your neck?" I asked.

"It's acting up again," she said. "My right arm is so numb and tingly I can't get anything done. It happens every so often, usually when my pulling is out of control."

"What's the association between pulling your hair and numbness and tingling in your arm?" I inquired.

"Well, there's this area at the upper left side of the back of my neck, right about here, that I enjoy pulling from for some reason," Pat explained, slipping her right index finger under the brace to demonstrate the location and grimacing with pain as she did. "The problem is that this part of my neck is not easy to reach with my right hand, which is the hand I use for pulling. Well, imagine spending two to three hours a day, your right arm wrapped behind your neck, and your neck bent forward, as you focus on finding more hairs to pull. Now imagine doing this for years… Talk about repetitive motion injury! I have a bulging disc in my spine as a result, and it's causing pain to radiate down my right arm. The brace is to immobilize my neck so I can avoid surgery."

"And does the brace help with the pain?" I asked.

"Yes, it does, as long as I wear it," Pat answered.

"Does it help in other ways, too?" I asked. "Does it reduce pulling as well by preventing access to your favorite pulling spot?"

"Well, yes," Pat answered, "but that's one reason I take it off when I should be wearing it. When the urge to pull is too strong to ignore, I simply take the brace off."

"Despite the pain?" I asked.

"Despite the pain."

"Despite the threat of neck surgery?"

"Despite the threat of neck surgery. Isn't that crazy?"

Dating Stress

"Well, they certainly get worse around stress," Pat replied, "especially dating stress. I'm an attractive—except for my hair—and successful mortgage broker, forty-two, still single, and with no prospects for intimacy as long as I have this problem. The thought of finding myself in an intimate situation that might expose my problem is enough to send me into a panicked frenzy."

"So the bald spots prevent you from dating because they're too embarrassing, and when you do find the courage to date, the stress around that leads you to pull even more," I recapped.

"Exactly," Pat concurred. "It's a vicious circle, and I'm caught in the center of it! I haven't gone out on more than two dates with the same guy for a very long time. The likelihood of some form of intimacy taking place on the third date if things go well is too scary to contemplate…What if he crosses the four-foot normal social distance and gets into my personal space? What if he approaches me in bright light for a kiss and spots the thick brown foundation covering parts of my scalp? What if he runs his fingers through my hair? What if? What if? What if?"

"That is really tragic, Pat," I said. "The idea that even with men you do like, you have to resist seeing them a third time and feel forced to end things prematurely…"

"Absolutely," Pat said. "I always sabotage things to turn the guy off and avoid seeing him again. Like this last guy Sebastian introduced me to, who turned out exactly as Sebastian had described: a handsome, gentle, successful Realtor—a nice Jewish boy, really. And did I say handsome? Well, it came up on our second date that his sister had OCD and, as kids, she would spend three hours in the shower every day while he waited patiently for his turn, and as a result, he now won't allow any of his clients to buy a house with less than two bathrooms…Well, instead of empathizing with his childhood experience or using it as an invitation to open up about my own personal struggles with rituals, I went on to make fun of his sister's OCD in the most insensitive way imaginable! And I wouldn't shut up! Imagine, half-bald me making fun of his poor sister's showering rituals! Talk about the pot calling the kettle black! Well, needless to say, the third date didn't happen.. . And when Sebastian started asking what went wrong, the best I could come up with was, 'Well why don't you date him if he's so perfect?' I don't have to tell you that I haven't forgiven myself for this fiasco yet…"

"So you were intentionally pretending to be a mean person to turn off a guy you really liked so he would not want to ask you out on a third date," I summarized.

Pat nodded, her eyes welling up. This painful real-life example of the consequences of her illness brought Pat's tragedy home to me. Her tears drew me in. More than at any point in my meetings with her, I was able to get past wig and brace to appreciate the real hurt that lay much deeper than the outside manifestations of her illness, disturbing as those were.

I struggled to show Pat I was caring without losing control over my own reservoir of feelings. My theory has always been that you have to project resilience and empathy, almost simultaneously. Any "breakdown" on my part could be interpreted by Pat as a sign of weakness or inexperience and might lead her to doubt that I possessed the emotional backbone and resolve needed to address her problem.

On the other hand, by closely identifying with Pat and openly and transparently sharing my feelings with her, perhaps to the point of tearing up in her presence, I might be- come more "human" in her eyes, thus enhancing our doctor-patient bond. But is this not what Sebastian and other people close to her attempted to do, without lasting success, and are patients not looking for something different from their doctors? And what about my own mental health? Should I not be protective of that, too? Is there not a limit to how much I can identify with patients' problems before I, too, succumb to depression, negatively affecting my own life and severely impairing my ability to help others? Should I not be more like an oncologist, a cancer specialist who empathically delivers bad news all day but who does not bring these tragedies home and is able to sleep peacefully at night?

My internal debate was interrupted when Pat's growing discomfort with the subject of dating and this sad memory started manifesting itself in pulling urges that she seemed close to acting on right there in my office. I could see her reach under her brace with her right hand to that favorite spot in the left upper back part of her neck. I shook my head in an effort to dissuade her from pulling, a gesture I hoped she would interpret as "Don't do it." I wanted her, instead, to process with me the negative emotions our conversation was bringing up and to discuss other ways to dissipate them.

But before I could say anything, I heard Pat's voice come out, almost pleading.

"Please…just one more," she whispered. Then, withdrawing her hand from underneath the cumbersome brace, Pat reached for a much more conveniently located hair sticking out from the side of her wig. With a deliberate, firm motion, as she held the wig in place with her other hand, Pat pulled one more hair—from her wig. I may be imaging this, but I think I saw Pat's tense facial features immediately relax.

Treatment

It is very common for people with trichotillomania to comment that, by the time they "catch" themselves pulling, it is too late and too much damage has already occurred. Increasing self-awareness aims to bring pulling into consciousness. I usually start by identifying with my patient the situations that are likely to trigger pulling. For example, after tracking my patient Laurie's trichotillomania problem over two weeks using a daily pulling log that I asked her to keep, it became apparent that Laurie's worst pulling occurred while driving. With this information, I could tailor an intervention that targeted this high-risk situation. I asked Laurie to keep a pair of gloves in her car to wear whenever she drove. This seemed to reduce her pulling by taking the tactile pleasure out of it.

Competing responses are more socially acceptable, harmless behaviors the person can substitute for pulling. These are usually objects that provide some tactile stimulation, such as a stress ball the person can squeeze when feeling an urge to pull, a rubber band to pull on, or a makeup brush to stroke.

Motivation enhancement helps people with trichotillomania understand and remember why they want to stop pulling. With the therapist's help, the patient develops a list of reasons for stopping. For Laurie, the list initially included feeling more comfortable in social situations, feeling like she did not have to explain herself to anyone, setting a good example for her children, and finding healthier ways to release anxiety. Laurie posted the list on her bathroom mirror to serve as a daily reminder. I kept a copy, too, updating it as needed based on Laurie's progress in therapy.

Changing the internal monologue involves confronting assumptions about pulling that provide justification for continuing the behavior. For example, instead of "I've done so much damage, what difference does it make if I pull one more hair?" the patient is taught to shift her thinking to "Hair pulling is like self-mutilation, and I deserve better than this." Instead of "I'll only pull one hair and stop," the puller is taught to say, "I've never been able to stop at one hair, so I'm not going to test myself."

As with OCD, anxiety can trigger trichotillomania. Relaxation training can diffuse stress, thereby reducing pulling. Helpful self-relaxation techniques include deep, rhythmic breathing, visualization of a pleasant, soothing scene, and progressive muscle relaxation where the person is taught to tighten and then relax each muscle group in sequence from the toes to the scalp. Patients practice these tools in the therapy session and then apply what they've learned in the outside world to reduce pulling when they feel anxious.

Research studies on medications for treating trichotillomania are limited but do suggest that the SSRIs and clomipramine—all serotonin-based drugs well established for OCD—can be helpful. However, for most people, medications should be combined with therapy, as this is likely to give better results than medications alone.

"Treating trichotillomania can be long and difficult," I warned Pat, "but trichotillomania is treatable, and you shouldn't let the effort and time it might take us to control the symptoms discourage you."

"I've never been in treatment before," Pat said, "and I'm as motivated as I can be to get better."

"You told me you were most likely to pull while sitting at your computer at work," I said. "Here, I want you to take this stress ball. Keep it on your desk at all times and try clenching it in your fist when you feel the urge to pull."

I handed Pat a squeeze ball that a drug company rep had given me. I believe he meant it for my personal use—a way for me to handle stress on the job, so I would subliminally associate the relief I got from squeezing the ball with the product he was marketing. It had Paxil emblazoned all over it in phosphorescent blue. The bright colors caught Pat's eye, and she seemed momentarily amused. She gave the Paxil ball a good squeeze and seemed to approve of its consistency. "I feel better already," she joked. Shortly after that, though, her amused look morphed into circumspection. "But the problem is, most of the time I'm not even conscious of pulling," she worried. "How can I reach for my squeeze ball if I'm not aware that I'm pulling in the first place?"

"Excellent point," I replied. "That is why there is a parallel component to this therapy to make you conscious of the behavior itself. It involves having you collect the hairs you pull every day and put them in individual envelopes with the date and number of hairs written on the outside of each envelope. You then bring the sealed envelopes with you to our weekly meetings, and we use them as an objective way to track your progress." Hearing this, Pat's circumspection changed into utter disbelief. And not without some irritation. "Did I hear that right?" she protested, sounding both incredulous and annoyed. "You're asking me to bring a week's worth of hair stuffed in envelopes to your office every week? Is this a joke? Did I forget to mention that sometimes I lick the hairs I pull? Do you still want me to collect them? I'm sorry, but this is a bit on the disgusting side, and I find it hard to believe that people actually do it! I'm afraid your treatment, Doctor, is too embarrassing for this patient."

"I agree that there is an embarrassing aspect to this, Pat," I said. "But some people do it—and with good results, I might add. One way to look at this is to say that we would be using the embarrassment factor to our therapeutic advantage, almost as a motivator. Here's how it works: the fact that you are saving and counting the hairs will make you more aware of the behavior, and the embarrassment of having to produce these hairs in my office every week will discourage you from pulling."

"I still can't believe this," Pat continued, already sounding a bit more resigned and a bit more accepting of the unconventional treatment recommendation. "Can't I just take a pill? Paxil, for instance? I already have their ball! It really would be a lot cleaner…"

"It would, for sure," I agreed. "But in my experience, behavioral therapy is at least as likely to help with trichotillomania as medications are. Plus, it is free of side effects!"

"Unless you consider embarrassment a side effect, that is," Pat quipped.

"I consider embarrassment in this case to be part of the intervention's mechanism of action." I said. "I look forward to seeing you in a week. Just make sure you seal those envelopes!"

Paperwork

"Pat, our trichotillomania patient, just stopped by," Dawn said. "She says she's sick with a cold—although she sounded perfectly fine to me! Anyway, she said she needed to rest and wouldn't be able to make it for her weekly appointment today. She did drop off some paperwork for you to review, though. She said it was important that I get it to your desk soon."

"Do you know what it's about?" I asked.

"I haven't a clue," Dawn answered, "but it looks very official. Seven nicely sealed envelopes, all dated and numbered, although the numbers don't seem to follow any sequence. Insurance company correspondence would be my best guess."

"I think I know what this is about," I said, feeling a bit guilty at having Dawn unknowingly handle a patient's hair—especially hair that might have been licked! At the same time, I really did not want to go into a detailed explanation of what Pat and I were up to. This was a hairy Pandora's box best left closed for now. "Just save the mail in her chart until her next visit," I said.

"I can sort through them now if you want," Dawn replied. "Her insurance probably just wants more documentation before they'll authorize more visits. You know how I can sweet-talk insurance companies into almost anything…"

"I know your clout with insurance companies, Dawn," I said, "but no, really, this should wait until Pat's next appointment…Have you had your lunch break yet?"

Progress

"The neon writing has rubbed off on my hands," Pat announced at the outset of the session. "I think I need a new squeeze ball!"

"That's a good sign!" I replied. "It means you've been taking full advantage of it. You've been doing the hair-collecting part of the treatment, too; I got your envelopes last week."

"And I have another week's worth for you here," Sebastian added, opening his black leather messenger bag to produce a stack of seven sealed envelopes. He looked numb and somehow mechanical as he handed over the envelopes, with none of the drama I had come to expect from him. Pat looked away. "It was either me coming with Pat today to hand-deliver these to you or Pat mailing them to your office," Sebastian added. "She has a very difficult time bringing the envelopes in, although she is religious about collecting the hairs!"

A quick glance at the numbers written on the envelopes revealed a slow decrease in the hairs pulled, from around 150 some two weeks earlier to about 100 now.

"It looks like you are doing a better job controlling your pulling," I commented.

"I'm more conscious of it," Pat explained, "and that translates into better self-control. Plus, I really don't want to have to bring them here, so when I pull now, it's when the urge is impossible to resist and the squeeze ball fails to make it go away."

"May I interject something here?" Sebastian broke in, looking more animated. "I mean, that is all fine and dandy, but it seems to me like we're missing the point. We're not addressing the root of the problem, if you will excuse the pun. I mean, what is causing this? Why is she pulling in the first place? Why does someone as normal as Pat self-mutilate like this? I can't see how squeezing a ball or collecting saliva-soaked hair can be a long-term solution…A band-aid maybe, but as long as the deeper issues troubling her are not addressed, it seems to me that the problem is likely to come back again."

"Well, what do you think, Pat?" I asked.

"I'm torn," Pat answered. "Part of me says, 'Whatever works, I'll take it,' but another part craves some kind of explanation, some kind of answer."

"I can understand your frustration, Pat," I said, "but—as is the case with so many conditions in psychiatry, and in medicine in general—we are far better at fixing the problem than at telling you exactly why you were the unlucky person who got it. Take diabetes, for example—"

"But this is not diabetes!" Sebastian interrupted, becoming louder and more irritated. "Can't you see? Deep inside, Pat-the-patient hates Pat-the-person, and this is her way of punishing herself. We need your expertise in reversing this, so she can start believing she deserves better. Unless she starts liking herself again, she will never stop this self-mutilation nonsense…When I brought Pat in here, I was hoping you would help us get there. I suppose I could have had her work in my salon, sweeping hairs off the floor and stuffing them in envelopes all day long. I guess that would have fixed the problem, too, but I chose to bring her here instead, hoping for more than that!"

"I could not agree with you more that Pat deserves better than to have to deal with this problem," I said, trying hard to hide my irritation at Sebastian's interference in the treatment Pat and I had agreed on, and which already seemed to be bearing fruit. I felt that a change in treatment approach could sabotage Pat's recovery, now in progress. I also wondered about the role his own history of unsatisfying psychiatric treatment might be playing. "I just do not believe that spending hours in expensive therapy to try to come up with a story that may or may not be true about why Pat pulls her hair will ensure that the behavior goes away," I added.

"And I can't see how stuffing hair in envelopes guarantees anything either," Sebastian snapped back.

Feeling that continued confrontation was unlikely to lead anywhere and hoping to talk with Pat alone at the next visit, I suggested we postpone any decisions regarding the future course of therapy until our next meeting, when we would have more data on Pat's progress. Then, clearly addressing Pat, I said, "My recommendation is for you to continue with the hair-collecting and squeeze-ball tools until I see you back in my office in one week." I then discreetly slipped a brand new phosphorescent stress ball into her bag.

The Absent Patient

"Pat is not exactly an ex-patient, Dawn," I corrected. "Not with a piece of mail arriving from her every day…In a strange and unique way, Pat remains a very active patient."

"In a very strange and unique way," Dawn quipped. Then, after a brief pause, she added, "I just can't understand why she hasn't responded to our calls. It's been almost two months already. Maybe I should stop by Sebastian's salon and check on her. I'm thinking of getting a perm before the baby comes anyway."

"Absolutely not, Dawn!" I interrupted. "Perm or not, you are not to have a conversation with Sebastian about our patient. That would be a breach of confidentiality, and I cannot allow it."

"My, my, are we short and testy!" Dawn exclaimed. "Who's the pregnant one here, Dr. A.?"

Besides the obvious ethical concerns around patient privacy issues, one explanation for my irritability with Dawn was my defensiveness around the mention of Sebastian, who, in a sense, had been right to confront me, although he could have done it more tactfully and without the I-could-have-told-her-to-do-that-myself attitude. Like him, doctors—and perhaps especially psychiatrists— want to understand the why behind the symptom and feel some insecurity admitting their ignorance. After all, as doctors, we are not only called upon to fix a problem; we have to try to explain it, too. Only after a satisfactory explanation can patients avoid the triggers that brought on the symptom in the first place and thus feel confident in their recovery and the permanence of the fix.

This powerful drive to explain mental illness has given rise over the years to some fabulously simplistic and often ultimately wrong hypotheses for mental disorders.

This powerful drive to explain mental illness has given rise over the years to some fabulously simplistic and often ultimately wrong hypotheses for mental disorders—from the "schizophrenogenic mom" whose aloof and diffident nature somehow led her child to start hearing voices as a young adult to, more recently, the conceptualization of major depression as simply a disease of "too little serotonin" that is easily treated with medications that raise the levels of this neurotransmitter in the brain. Doctors should feel less threatened answering "I don't know" to questions that push the boundaries of medical knowledge, and patients should not necessarily interpret this "I don't know" to mean "I can't help you."

But even in the midst of my defensiveness around my inability to produce a satisfying cause-and-effect story to explain Pat's pulling, I could not help but notice that the discreetly written numbers in the upper left corner of Pat's daily envelope continued their steady decrease, from around 150 on the envelope at the bottom of the pile to less than 15 as the two-month anniversary of our last meeting approached.

Then, at exactly two months after our last encounter, Dawn paged me with her phone number followed by 9-1-1. I called her right back. "What's the emergency, Dawn?" I asked.

"Dr. A.! Pat is here!" she answered, out of breath. "She wanted to personally drop off an envelope with me, but I told her I wasn't comfortable playing the intermediary for her anymore, and she would have to give it to you in person this time. Should I schedule an appointment for her, or…

"I suppose I can squeeze her in right now," I interrupted, trying to downplay my excitement at seeing Pat again. "Have her come up," I said. "No! Dawn, wait! Is she alone?"

"Yes, she is. Don't worry!" Dawn reassured me. "I'll send her right up."

Barely two minutes later, Pat and I were sitting face-to-face in my office. She exuded an air of both refined elegance and serious business in her white pantsuit with oversized lapel, decorated with a large sunburst brooch whose shiny silver surface echoed the large metal hoop handles of her white leather purse.

It was a mark of undeniable progress that I was struck by other aspects of Pat's appearance before focusing on her hair. Pat was no longer presenting herself as someone who, because of deformity or extreme self-consciousness, was working hard to go unnoticed. That afternoon in my office, Pat had a physical presence, and a self-assured, attractive one at that! As to her hair, it was not lifeless or perfectly symmetric (as in fake), not overly luscious or flowing (as in exaggerated hair product advertisements), and not uneven, brittle, or combed-over (as in "trich hair"). It was pulled back in a neat-looking bun on the vertex of her head, with no random hairs sticking out from the bun or the sides, and no evidence of redness, bald spots, or makeup on the scalp underneath.

"You look very good, Pat!" I exclaimed. "But where have you been?!"

"I have something to give you," she said, avoiding my query into her extended absence.

"OK, but you did not answer my question," I insisted. "It's been two months!"

Before I could press her further, Pat slowly separated the large silver hoops of her bag, then quickly snapped it open to reveal a familiar-looking envelope.

"Please open it," she requested, handing me the envelope. "I'll explain—or try to explain—afterward."

My hesitation and confusion must have been visible as I assessed the envelope, which carried neither the customary flower series stamp nor the number of hairs on it. Just "Dr. A." in large script.

My hesitation and confusion must have been visible as I assessed the envelope, which carried neither the customary flower series stamp nor the number of hairs on it.

"Just open it," Pat insisted. "That's the last thing I will ask you to do for me."

So I did. I opened the white envelope labeled "Dr. A." and found it completely empty inside.

"I'm down to zero!" Pat said, flashing a big smile.

"That's great news, Pat!" I said, my surprise visible. "I'm proud of you."

"I do feel like I owe you an explanation, though," she said. "After our last meeting, I felt like…"

"You don't really owe me an explanation, Pat," I interrupted. "Feel free to explain yourself if you want, but you don't 'owe me an explanation.' I was just worried about you, and I'm thrilled to see that you are doing so much better now."

"I'm doing better for sure," Pat said. "In fact, I can't stay too long! I'm meeting my date in a half-hour."

"You're starting to date again! That's as good a sign as any that things have drastically improved. Is it the same nice Jewish boy you liked so much, by any chance?" I asked, excited that a promising, prematurely aborted relationship might get another chance. "He seemed to really like you, too, as I recall, but you sabotaged the whole thing out of embarrassment that he might find out."

"Who? God, no!" Pat said, letting out a loud laugh. "Didn't you hear? Well, there's no reason why you should have heard…"

"Didn't I hear what, Pat?" I asked, intrigued.

"Well, it turns out he was…Well, he and Sebastian are, umm, together…" Pat said hesitantly. "As like, dating each other," she added. "In fact, Sebastian perceived you as wanting me to pursue my relationship with Neil—that's the guy's name—which I think made him a little jealous. In retrospect, that explains some of his outright hostility toward you last time we all met. I'm very sorry about that, by the way. You didn't deserve it at all!"

"That's OK," I said. "H2O under the bridge, as Sebastian would say. But I must tell you I'm very confused now. Wasn't Sebastian the one who introduced you to Neil in the first place?"

"He did, he did," Pat conceded, "but I'm now convinced that he was using me to test some hypothesis he had about the guy all along. Frankly, I'm confused, too. I could sense Neil was interested in me, but I also know he's seeing Sebastian now. Maybe he's bisexual or something… Anyway, it doesn't take a psychiatrist to guess that I'm a little mad at Sebastian right now. But it's nothing that he and I won't get over in time."

"Well, this is all very fascinating but also very sad, Pat," I said, wanting to give her an opportunity to process her feelings around what had happened. "I know how close you and Sebastian were, and I hope you can salvage your friendship."

But the non-doctor part of me was also simply curious, in a way that was perhaps inappropriate—more gossipy than clinically relevant to my patient. "Tell me more!" I said. "Do you think the two of them are a good match?"

Fortunately, however, Pat would not indulge me. "Well, I could go on and on analyzing this," she said, "but what purpose would it serve besides prolonging the same pointless drama? The fact is, I've moved on, and it's all H2O under the bridge at this point… Plus, you don't want me to be late for my date, now, do you? Thanks for everything, Dr. A. Really, thank you."

With that, Pat stood up, gave me a hug, and disappeared into the labyrinthine hallway of our clinic, sounding a lot more confident in her step and a lot less anxious.

The Psychiatrist's Lot

But what to do with two months of hairy correspondence? Except for the final empty envelope, which I held tightly in my hands and then pinned to the wall in my office, I pushed the rest of the stack toward the edge of my desk, letting it drop off into the trash can. The thud of the falling pile as it hit the bottom caused a feeling in me that, however tinged by a sense of loss and separation, I can still best describe as satisfaction.

Excerpted (with permission) from Compulsive Acts: A Psychiatrist's Tales of Ritual and Obsession by Elias Aboujaoude, MD. Now available in paperback and on sale. For more information and to order, please visit the publisher's website, UC Press, or read reviews and purchase at Amazon.com.