New Guidelines for Tourette Syndrome Treatment Call for Behavioral Therapy Before Medication

New guidelines meant to help neurologists treat people with Tourette syndrome call for waiting to see whether symptoms get worse and then trying behavioral therapy before resorting to medications.

The guidelines were released Monday in Neurology, the medical journal of the American Academy of Neurology (AAN). The AAN’s annual meeting has brought 14,000 people this week to the Convention Center. The group held a news conference Monday to discuss the guidelines, the first for American neurologists. See the full article here.

The HABIT Clinic, housed in Psychology Houston, PC and founded by Drs. Reuter and Mouton-Odum, is the only clinic in Houston with CBIT trained providers. For more information on The HABIT Clinic, please see our website here.

An Early Psychologist’s Reactions to the 25th Annual Trichotillomania Learning Center Foundation for Body Focused Repetitive Behaviors Conference

by Hannah Sommer Garza, PhD

Wow! What a weekend! I’m flying back to Houston from San Francisco reflecting on my experiences this weekend at the 25th Annual Trichotillomania Learning Center (TLC) Foundation for Body Focused Repetitive Behaviors (BFRBs) Conference ( with a content smile on my face. From inspirational talks, shared experiences, new information, and good times with friends and colleagues, the weekend was jam packed with great moments. It’s hard not to leave the Annual TLC Foundation for BFRBs Conference feeling inspired and connected with other members of such a warm and collaborative community. If you’ve never been to the TLC Foundation for BFRBs conference YOU MUST GO!! Like, for real, you must go! There are events/talks/workshops/support groups for young children, adolescents, adults, supporters of those with BFRBs, researchers, and clinicians. There is something for everybody at all times during the Friday through Sunday conference, including social events and entertainment. I wish I could have been in multiple places at once, because it was hard to narrow down what events to go to this year. I will share some of my stand-out experiences from this year’s conference, and will just have to catch the ones I missed at next year’s rendezvous.

Friday’s Keynote

Daaaaaang…Milcho is a powerhouse! What a wonderful role model for what it means to love yourself and live your best life. Milcho is a musician and motivational speaker from Miami. She is a dynamic and sassy Latina who owned the stage. She would periodically pause for a photo op, showing off her best angles with a hip pop. She was full of energy and love, and offered some truly, truly, truly inspiring words to the group about working hard for yourself (and nobody else), loving yourself, and doing what makes you thrive. After her light-hearted and touching video compilation of some of her friends practicing talking to themselves in positive ways while looking in the mirror, she prompted the audience to open the provided handheld compact mirror and say supportive words like “I like you” and “I have a crush on you” #selfcrush. She rocked it!

Saturday Talks

Early Career Award & ECAP Research Data Blitz

I had the very special honor of being selected by the TLC Foundation for Body Focused Repetitive Behaviors as a recipient of the Early Career Award Program (ECAP) for Clinicians. There were 5 clinician recipients and 6 researcher recipients. As part of the award, the eleven of us were able to meet with Saturday’s keynote speaker, Susan Swedo, MD, and several of the TLC Foundation for BFRB expert clinicians and researchers to learn from their experiences and how to continue our careers within the TLC community. What a fabulous opportunity to learn from some of the greats and to share ideas about how we can continue to grow our community and our ability to effect meaningful change.

As clinicians, we were paired with an expert mentor to continue to consult and network with after this weekend’s activities. I am so thrilled to have been paired with Charles Mansueto, PhD, Director of the Behavior Therapy Center (BTC) of Greater Washington ( and developer of the Comprehensive Behavioral (ComB) Treatment model for BFRBs. In addition to the obvious WOW factor of his accomplishments and influence on the BFRB community, he is one of the most hilarious people I have ever met. He’s one of those people who is so engaging and friendly, and has so many laugh-cry-inducing stories that it is a true pleasure to have him as a new mentor.

Later in the day, I attended an ECAP data blitz where three of the ECAP research award recipients shared their research proposals and preliminary results. Their research topics are so exciting and promising for the field, and I am very much looking forward to what they find. From genetic sequencing of parent-child trios, drug trials of intranasal glutathione (GSH) on mice with barbering and ulcerative dermatitis (proxies for trichotillomania and chronic skin picking in humans), and implementation of a self-help online application for chronic skin picking, these ideas have some phenomenal and far-reaching potential for the BFRB community. I’m excited to see what they find, and excited to see the future faces of BFRB research. Stay tuned!

CBT 101 Talk to Teens & Adults

My colleague at Psychology Houston, PC, Dr. Tyson Reuter, and I did two talks this year—our first ever talks at this conference. As clinical psychologists with specialties in cognitive behavioral therapy (CBT), adolescents, and BFRBs, we were PUMPED to share our knowledge about CBT and tips/tricks for challenging and changing pesky thoughts. We introduced principles of CBT, briefly introduced behavioral strategies for managing BFRBs, and emphasized practice with challenging and changing unhelpful thoughts. We were especially impressed with our adolescent group who were eager to share their experiences and to practice using some of the principles we were outlining. They were awesome at recognizing their own thinking traps and helping each other challenge them. Dr. Reuter and I intend to offer the talk year after year at future conferences, as long as there is demand for it.

Emotion Regulation Talk

I also attended Nancy Keuthen’s, PhD talk on Emotion Regulation and BFRBs. Dr. Keuthen is a Harvard psychologist. Her talk and skills primarily focused on dialectical behavior therapy (DBT) skills, tailored to people with BFRBs. I loved her overview and explanation of the skills, which was a nice review for me, with sprinkles of planned practice and intention with how to implement them after leaving the conference. She asked each of the participants in the audience to write in their provided PowerPoint handouts their personal goals in various emotion regulation areas. I found her talk to nicely bridge the gap between talking about certain strategies and helping people to actually implement them. It’s one thing to talk and talk and talk about swimming, but until you actually get into the pool, you have no idea how to swim.

Readiness for Change Talk

Into the meat of the afternoon on Saturday, I attended our very own Psychology Houston, PC Director, Dr. Suzanne Mouton-Odum’s talk on Readiness for Change. She talked about the Prochaska & DiClemente (1983) Stages of Change model and what that may look like for someone with a BFRB. She talked about steps for moving yourself along the stages of change, and differences between motivation and readiness. One of the most powerful things I took away from her talk related to the importance of acceptance as part of the change process. Because behavior change is hard, in additional to being motivated AND ready to change, you must also be able to accept the fact that your life will transform from what you know it to be now. Now really think about that. Your life will transform from what you know it to be now. It’s unrealistic to think that the only thing that will change in your life is to stop the BFRB behavior. If you’re holding onto that idea, you’re not ready for change. Working on acceptance and readiness at that stage will help move you along toward behavior change. She also normalized frustrations with getting stuck and the cyclical nature of BFRB recovery, alongside skills for problem-solving and acceptance to move toward change.

Dinner and Fundraiser

Although I wasn’t able to attend the fundraising dinner at this year’s conference (due to my only opportunity to catch up with a good friend in San Francisco), I heard from colleagues and friends that the food and entertainment was fabulous. The fundraising dinner is an integral part to the ability of the TLC Foundation for Body Focused Repetitive Behaviors to provide outreach services and to fund research. Federal funding for psychological research is sparse in general, and is even less likely to go to BFRB research for various reasons. That leaves the TLC Foundation for BFRBs organization to essentially stand alone in order to continue to study the etiology of BFRBs and potential mechanisms for recovery. That means that in order for us to continue making forward progress, we RELY ON YOU. If you’re interested in donating to the cause, I encourage you to reach out to the TLC Foundation for BFRBs ( Give what you can give, whether that’s $20 or $1000. Any bit moves us forward in hopes of helping more and more people find relief. For that, we thank you!

Reactions and Takeaways

One of my reactions may sound controversial on the surface, but I hope I can express my thoughts clearly enough to avoid them from being misunderstood. Perhaps I’m also biased as a behavioral psychologist, but I do notice myself feeling somewhat discouraged when I hear the results of some of the drug trials searching for a medication treatment for BFRBs or a “cure.” I find that the proposals sound extremely promising, and I get my hopes up about an “easy” fix. Then the results are described by the research experts, and there’s kind-of-sort-of some support…but we’re still left without clear answers.

However, there is support for behavioral treatments for BFRBs as outlined by the TLC Foundation for BFRBs Scientific Advisory Board, a panel of expert BFRB clinicians and researchers. Because behavior change is hard and involves a profound personal transformation (among other factors), my fear is that many of the folks with BFRBs are waiting for this magic medication (or supplement) to change their lives. I fear that in some way this reliance on finding a medication encourages people with BFRBs to “wait to live their lives” for when this “cure” is discovered. Since this “cure” could be around the corner, there is in some way a sort of excuse or lack of urgency to change a behavior that you may want to change. If this is the case, my heart hurts a bit. I feel so much connection to this community and want so desperately to be a resource for people who want to change this behavior to find their version of recovery (whatever that means to them). I can feel the strong desire to find a solution, and I want to help people find that as soon as possible. The truth is that the “cure” could be around the corner, but it also may not be. Why wait? Why not work toward change, learn some skills and ways to manage your BFRB? Borrowing from Milcho’s message, empower yourself. Do this for you. Love yourself enough to take things into your own hands.

Research co-authored by Dr. Tyson Reuter receives national coverage

Research co-authored by Psychology Houston’s own Dr. Tyson Reuter was recently recognized by Huffington Post as one of the “most important scientific studies for parents of 2017” and has received national coverage by CNN, USA Today, The Atlantic, US News and World Report, NY Daily News, and Daily Mail. Congrats Dr. Reuter!

The study is called: Childhood Corporal Punishment and Future Perpetration of Physical Dating Violence

SMART Goals: Getting Resolutions to Stick

Written by Hannah Sommer Garza, Ph.D. and Tyson Reuter, Ph.D.

It’s that time of year when the holidays are over, and the new year has begun. New Year’s resolutions have started, and may still be on the top of the brain. If you’re like most people, you may have started past year’s resolutions with determination…until sticking with them slipped off the radar. We know that behavior change is hard, but can be done successfully when keeping certain things in mind. In particular, you want to plan SMART goals.

SMART is an acronym standing for Specific, Measurable, Achievable, Relevant, and Time-Bound. These characteristics have been found to help guide goal-setting, and to ensure that your goals are clear and able to be obtained. SMART goals were first introduced by George Doran, Arthur Miller, and James Cunningham in a 1981 business journal, offering suggestions for how to improve project management in business settings. The acronym stuck and the principles have been found to be successful with achieving all kinds of goals, including New Year’s resolutions. Below is an explanation of how to create SMART goals and tips for how to be successful sticking with those New Year’s resolutions.

It is very important to be specific about what your goal actually is in order to know whether or not you’ve achieved it. Consider what you want to accomplish and why. Perhaps you want to improve your health, or to get more organized. What does that really mean to you? How would you know that your health has improved or that you’ve gotten more organized? Specify exactly what you want to accomplish. Instead of having your goal be too general (e.g. to get healthy), make it more fined-tuned by saying you want to lose a certain number of inches, or reduce your blood pressure to levels advised by your physician. The more specific you can be, the better! This will help you to stay on track with your goal AND to know how you’re doing with it. If your goal is too general, it is all too easy for excuses to sneak in and get you off track.

Select a goal that has identifiable, measurable outcomes. Measurable goals help you know how your progress is going throughout the year. Also importantly, being able to measure your goal lets you know once you’ve accomplished it! (which is the whole point, right?!). Below is a list of common New Year’s resolutions and some ideas for how to measure progress with them:

“I want to exercise more”
Attendance at a certain number of exercise classes
Number of minutes exercising
Number of steps per day
Completion of an established exercise program (e.g. P90X)
“This year, I’m going to lose weight”
Pounds as weighed on a scale
“I’m finally going to start to eat more healthily”
Number of calories eaten per day
Number of meals consumed with specified foods (i.e. food items you’d like to eliminate and/or food items you’d like to increase)
Adherence to a certain meal plan (e.g. Whole30 or Paleo)
“I’m going to focus more on my health”
Number of minutes exercising
Attendance at doctors appointments
Number of times engaging in health-related behaviors (e.g. flossing, taking vitamins)
“I want to learn a new skill or hobby”
Number of classes attended for new skill or hobby
Benchmark of proficiency appropriate for new skill or hobby (e.g. passing scores for new language quizzes)
“I’m going to focus more on my personal wellbeing”
Amount of time spent on personal wellbeing activities
“I want to spend more time with family and friends”
Amount of time spent with family or friends
“I’m going to give up drinking alcohol”
Number of standard drinks consumed
Number of days when alcohol was consumed
“I’m giving up cigarettes”
Number of cigarettes smoked
Number of days when cigarettes were smoked

This is not an exhaustive list, but can hopefully get your ideas flowing about how to measure your progress toward your selected goals.

Now that your goal is specific and measurable, you want to also make sure it’s achievable. Thinking through the logistics to see how to achieve your goal is very important. Consider what it would specifically take to accomplish this goal. What are the requirements or possible constraints? Being as detailed as possible and thinking through the logical steps will help you to be better set up for success. For instance, if your goal is to cook more meals at home, what would it take to achieve that goal? You may need to plan when you’d go to the grocery store, time to meal plan, time to cook, etc. Think about what it would take to make those aspects of the goal (or sub-goals) happen. Also consider potential speed bumps to meeting your goal, like if you’re out of town or out of your typical routine. Knowing how to handle whatever gets thrown at you will help you stay true on your path to your goal.

After ensuring the goal is specific, measurable, and achievable, the next step is to be sure it’s relevant. Is this a worthwhile goal? Even if the goal is worthwhile, is this the right time? Sometimes we have difficulty achieving our goals when the timing is off. Think about whether or not you realistically have the time and are willing to make the changes in your life necessary to achieve your goal at this time. Is this goal in line with your long term objectives? If your goal is not in line with your bigger picture objectives, then it may be important to temper your expectations. You are more likely to find success with sticking with goals that are in line with your overarching values.

With specific, measurable, achievable, and relevant goals, there is one last step. Finally, plan to keep your goal time-bound. Think about how long it will take you to accomplish your goal and give yourself a “due date.” Having a mental finish line for when you plan to achieve your goal will help to keep you on track. Also consider setting time boundaries on when the goal will reset–every day, every week, or even every month. This technique can help you if you have a down period where you weren’t successful with your goal. Instead of metaphorically throwing the baby out with the bathwater, the next week (or whatever time duration you’ve selected) is a fresh new week.

Getting Resolutions to Stick
Now that you know all the pieces of SMART goals, it’s time to tie them all together. As you plan your path of success with your New Year’s resolutions (or any other goal), consider how to make the goals Specific, Measurable, Achievable, Relevant, and Time-Bound. Also, learn from your past experiences of struggling to achieve goals AND when you’ve met them. What were the features of the goal and your attention to them that helped you be successful? What are the features that need to be tightened up this time to be more successful than before? Remember that times of struggle can be learning experiences, and are often necessary aspects of future success. Now, put all the pieces together and make your goals happen!

Putting It All Together

Let’s say your goal is to exercise more. Using what we’ve now learned, let’s make the goal SMART!!

“Exercise more” is too general. What does “more” mean, specifically? Running? Biking? Getting involved in exercise classes?

And, it must be measurable. How many runs? How many miles? Minutes? Steps?

Of course, the goal must also be achievable, which goes hand in hand with relevant. Are we talking about running a mile, or a marathon? It’s great to aim high, but what is truly and honestly realistic? After all, we’re after outcomes. Will you exercise in the morning or at night? Do you have all the gear you need to be ready to do the intended exercises? If not, what do you need to do to be ready?

Finally, let’s put a time frame on this goal. How long will it take to reach our clearly defined, measurable, and achievable goal? When will we assess our progress towards it concretely?

So, instead of saying “This year I will exercise more,” a better goal may be something like “This year, I will run in the evenings after work 3 days a week for 20 minutes in my neighborhood.”

Comprehensive Model for Behavioral Treatment (ComB) of Trichotillomania and Other Body-Focused Repetitive Behaviors (BFRBs)

Written by: Hannah Sommer Garza, PhD

What are Body-Focused Repetitive Behaviors (BFRBs)?

BFRBs refer to a group of related behaviors where the individual repetitively touches specific parts of the body (e.g. hair, nails, skin) in a way that can cause damage. BFRBs are not tics. Common BFRBs include hair-pulling disorder (trichotillomania), skin-picking disorder (excoriation), nail-biting (onychophagia), and knuckle-cracking. Individuals may engage in a single type of BFRB (e.g. hair-pulling) or a combination of them throughout their lifetime. These behaviors tend to cluster together within families, suggesting a genetic component to their presentation. For more information, check out this website. Fortunately, all BFRBs can generally be treated very similarly. This blog focuses on one particular evidence-based treatment for BFRBs, the Comprehensive Model for Behavioral Treatment (ComB).

The ComB model was developed by Charles Mansueto, PhD and his colleagues at the Behavior Therapy Center of Greater Washington. It is one of the leading cognitive behavior therapy (CBT) approaches to treating BFRBs, by identifying the function of the target behavior (e.g. hair-pulling or skin-picking) and creating a targeted replacement for it. The ComB model is also endorsed by the Trichotillomania Learning Center (TLC) Scientific Advisory Board, a board of BFRB expert researchers and clinicians. The ComB model assesses five functional domains known to be associated with the promotion of the BFRB. The five domains are: Sensory, Cognitive, Affective, Motor, and Place. The common acronym for them is SCAMP. I will outline each of the domains below.


The Sensory domain encompasses any sensory experience that promotes the BFRB. More specifically, any visual, auditory, tactile, oral, or olfactory experience that occurs before, during, or after the BFRB that promotes engagement in the BFRB. Check out this video on the Sensory domain from a BFRB expert, Suzanne Mouton-Odum, PhD.

One theory suggests that people engage in BFRBs as a way to soothe their central nervous systems. Throughout a given day, there are various and ever-changing sensory experiences we encounter. This can throw our central nervous system out of whack, so we do our best to self-regulate. One method of self-regulating could be through using BFRBs to either amp up the nervous system or to calm it down in response to environmental or internal experiences and to try to reach a form of homeostasis.

The assessment of this domain involves identification of sensory experiences associated with the target behavior. For instance, an individual with trichotillomania may notice hair-pulling sensory experiences that promote pulling to be: noticing a hair out of place (visual), feeling a kinky or coarse hair (tactile), enjoying the sound of the eyelid slapping back after pulling eyelashes (auditory), rubbing the pulled hair on the lips or sucking on the bulb (oral), or enjoying the smell of the bulb after pulling (olfactory). Examples of sensory experiences that promote skin-picking include: seeing a pimple (visual), feeling the dry or flaky part of a scab (tactile), enjoying the sound of skin flaking from a scab (auditory), swallowing picked skin (oral), or enjoying the smell of the picked blackhead (olfactory).

Once the triggering and maintaining sensory factors have been identified, the goal is to develop a functional replacement of those sensory experiences to have in place of the BFRB or to prevent the sensory trigger from occurring. That’s where a significant bulk of the treatment work comes in, involving a series of “experiments” to find a helpful combination of sensory replacements that will work for you specifically. Be a detective in your experiments. If a strategy is or is not working, find out why or why not. That will help you to get more targeted in finding the sensory interventions that will work best for you.

Some ideas for preventing sensory triggers could include dimming bathroom lights and covering mirrors to reduce visual exposure to hairs out of place or pickable skin. One could also preventatively use some sensory strategies to get ahead of BFRB urges. In terms of developing a functional replacement of the sensory experience, it’s best to try to recreate the enjoyable sensory experiences associated with the BFRB by finding the perfect fidget toy or tactile distraction. The ideal fidget will be one that most closely mimics the sensory experience associated with the BFRB. Oriental Trading Company has some great options for fidgets, but you can also get creative with household items. For example, makeup or paint brushes can usually mimic real hair at various lengths. If short, stubby hairs provide an enjoyable sensory experience, try cutting the paint brush bristles to be shorter in length, or try using a toothbrush or eyebrow brush to recreate the coarse hair sensation. Chewing gum or having suckers can be strategies for oral sensory experiences. Popping bubble wrap can also be a great way to create an auditory sensory experience. Ultimately, get creative with what you can use to recreate your sensory experience instead of engaging in your BFRB.


The second domain in the ComB model is Cognitive. Cognitive is just another word for thoughts. In terms of BFRB assessment and treatment, we’re specifically talking about thoughts that cue BFRBs or promote BFRBs in some way. Check out this video for more information on how thoughts relate to BFRBs in the ComB model.

The assessment of this domain involves identifying thoughts that occur before, during, or after the BFRB that are associated with the BFRB. These could be thoughts that enhance the desirability of engaging in the BFRB. For instance, “this hang-skin is uneven so I need to ‘fix’ it,” “I will only pull a few more hairs and then I will stop,” “picking helps me feel better,” or “it’s too much effort to get my strategy.” Other thoughts could be those that reward BFRB engagement, such as “yes, I got out the whole hair bulb” or “now my gray hairs are gone and that’s much better.”

Treatment within the cognitive domain involves targeted challenging and changing of those thoughts that promote the BFRB. Start to challenge the thought by looking at realistic evidence. Is the hang-skin really uneven? Is picking it really going to fix it? What are the costs to picking it? Is there another way to address it without picking it? You can also find motivating and helpful thoughts to cope with tough urges. For instance, “this urge is at its peak, but it will pass,” “this urge is hard to resist, but you can do it,” “I have found success with strategy X and can easily get/use it right now,” or “you’re making so much progress already, keep it up.”


The third ComB domain is Affective. Affect just means emotions or feelings. Oftentimes, people engage in BFRBs as a way to regulate emotions like nervousness, anxiety, frustration, or sadness. People may also experience certain emotions after BFRB episodes, like satisfaction, or even guilt, embarrassment, or shame. Check out this video for more information on the ComB affective component.

Assessment involves identifying emotions that may trigger the BFRB as well as those experienced after engaging in the BFRB. The first step is to build awareness of emotional experiences and how they relate to picking or pulling. Some people are already pretty good at noticing and labeling emotions as they are experienced, but for many people, this can be challenging. If you are someone who is wanting to increase your awareness of emotional experiences, try first paying attention to physical changes in your body. Do you notice your heart race increase, becoming physically hot, or having an upset stomach? Sometimes, these physical experiences are more readily captured, and can be neon sign reminders to connect them to an emotion. Additionally, you can pay attention to big changes in your behavior to try to capture feelings. If you notice that you are crying, avoiding something important, or are yelling at a family member, these could be signs that you have an associated emotional reaction. Ultimately, listen to your body cues or behaviors to get better at understanding what you’re feeling. As you better understand what you’re feeling and what kinds of situations you tend to feel that way, you may start to notice if your BFRB serves some sort of self-soothing or emotionally-regulating function. If so, then you can use affective coping strategies for managing BFRBs.

For many people, they engage in BFRBs when they feel stressed or overwhelmed. Affective coping strategies are designed to help manage the feelings associated with the BFRB. Therapy can help you learn healthy coping strategies for managing emotions. Some examples of affective strategies are: taking a bubble bath, going for a walk or run, deep breathing, yoga, journal writing, talking with friends, listening to soothing music, addressing procrastination, or managing interpersonal conflict. Some medications have also been found to reduce emotional distress.


The fourth domain of the ComB Model is Motor. The Motor domain captures the person’s awareness of and ease of engaging in the BFRB. Awareness is HUGE for addressing all of the other domains. Otherwise, it’s like playing darts in the dark in terms of selecting targeted interventions and strategies. Check out this video on the ComB motor domain.

The key here is keeping wandering hands busy and/or making it a little more difficult to engage in the BFRB. One of my first suggestions to people when they start BFRB treatment is to wear some kind of block. This may look a little different for different people and depending on the BFRB, but the idea is to wear something that blocks your ability to do the BFRB outside of your conscious awareness. Wearing blocks can be an especially helpful way to notice features of the other ComB domains that are able to be targeted for intervention. For many people, it also makes it nearly impossible to engage in the BFRB when wearing a block. Some examples of blocks are: wearing finger bandages, wearing a hat, wearing band-aids over cuts or scabs, wearing long sleeves or pants, and wearing gloves. Other motor strategies that keep wandering hands busy are: throwing away tweezers, staying active, using a fidget toy, putting on lotion, and knitting or other crafts.


The fifth and final domain of the ComB Model is Place. The Place domain encompasses the environment, location, time of day, and activity that promotes the BFRB. Check out this video for more information on the Place domain of the ComB model.

Assessment the kinds of places where BFRBs occur. Are there certain places where you tend to pick or pull? Do you primarily engage in the BFRB alone, or also when around other people? Do you find that you almost always engage in your BFRB when feeling tired or at the end of the day? Are there certain activities you’re doing where you notice more BFRB action, like checking email, writing a paper, doing homework, or watching TV?

Once you’ve identified certain places where BFRBs are more likely to occur, treatment in the Place domain involves tweaking those environments to make it more difficult for you to do the BFRB. Some examples may include: dimming the bathroom lights, covering mirrors, wearing make-up, wearing hair pulled back, or placing reminder notes in high-risk areas. If you notice patterns in the types of environments where you engage in your BFRB, then you would benefit from having preventative strategies in place for better managing those situations without picking or pulling.

How Treatment Can Help

Behavior change is hard!! While some people can make progress treating their BFRB alone, there are many powerful benefits of going to therapy for your BFRB. Through working with a specialist, you can build skills for identifying triggers and coming up with successful interventions that are supported by scientific research. The therapist can also help you to work through tough issues or barriers that may be getting you stuck. It can also be helpful to bounce intervention ideas off another person with experience treating BFRBs. Together, you can find strategies that will be realistic for you to use in your life. For instance, your therapist can work with family members to help educate them about BFRBs and to learn ways to be more supportive of your treatment efforts. Also, for many people, therapy is one of the first times they’ve felt able to talk openly about their BFRB without being judged for it. Ultimately, through support in therapy and some hard work, you may be better able to learn ways to change your BFRB behaviors. You are not alone, and help is out there!


Mansueto, C. S., Goldfinger Golomb, R., McCombs Thomas, A., & Townsley Stemberger, R. M. (1999). A Comprehensive Model for Behavioral Treatment of Trichotillomania. Cognitive and Behavioral Practice, 6, 23-43.

Healing after Harvey

Written by:

Hannah Sommer Garza, PhD, Rosie Polifroni, PhD, & Tyson Reuter, PhD

Healing after a natural disaster is difficult. There’s no sugar-coating that fact. Hurricane and Tropical Storm Harvey was considered the largest natural disaster in the history of the United States, and it hit us right here in the Texas coast. Even though the storm itself has passed, it will take time and significant effort for the people impacted to heal. Many people who were impacted by Harvey have likely experienced a range of feelings–fear, concern, numbness, anger, sadness, grief, and maybe even feelings of appreciation and hope. It may be difficult to truly know how to move forward emotionally.

Thankfully, research shows that humans are incredibly resilient beings even in the face of disaster. The vast majority of people impacted directly by Harvey will recover. That is not to say that the recovery will happen overnight. This was a huge natural disaster, and temporary disruption is to be expected. However, there are some things you can do to propel yourself forward in the process of healing. In particular, start with your go-to stress management and coping strategies that have helped you manage difficult times in the past. Below, we’ve included some research-supported suggestions for coping that we hope will help you to move forward with healing after Harvey.

Give Yourself Time

Being distressed after a natural disaster is normal and to be expected. Allow yourself time to grieve and to process what has happened, and anticipate that this will be a difficult time in your life. Remember that it is the norm to bounce back within a few months of the event.

Seek Social Support

Get support from people who understand what you’re going through and who are willing to lend a hand (or an ear) to help you get through this difficult time.

Benefits of Seeking Social Support. There are three huge emotional benefits to getting connected with your community in response to a natural disaster. First, you will see that you are not alone. Humans are social creatures, and we are hard-wired to be connected with others. Knowing that you are not alone, even when going through hard times, can ease the struggles as you heal. Second, by talking with other Harvey survivors, you may pick up some helpful coping strategies that they have been using to get through these tough times. Third, research tells us that individual resilience, which is the capacity of a person to bounce back from adversity, is dependent on a larger systems-level resilience (i.e., community). In particular, social connection helps to build emotional resilience following disaster (Boon, 2014). As Houston residents, we’ve seen first-hand the awesome, selfless, and inspiring spirit of this city to support one another following Harvey. Get connected with your neighbors and other parts of your community as you heal.

How to Get Support. The most natural instinct for so many who will begin to grieve following Harvey, will be to withdraw and isolate, which, in turn, will lead to further anxiety and significant depression. Instead of withdrawing, consider reaching out. Reach out to family members, romantic partners, friends, neighbors, church or temple staff, others who have lost their homes too, and seek mental health support. If you are asking questions like, “why me?”, “why our home?”, “what do we do next?”; know that you are not alone. On the other end of the phone, across the street, at a shelter, at your church, at your work place, and even at your child’s school, is someone who wants to help you. All you have to do is reach out. Reach out for that support that is waiting. Reach out once, twice, ten times. You are not a burden. Your network of those who want to help you will provide immeasurable comfort, if you let them.

How to Give Support. Let’s also take a moment and speak to those of you who know friends, family members, and even acquaintances, that have lost everything and who may be finding it hard to reach out and ask for help. You are on the front lines of helping and giving. Don’t be afraid to make a phone call, send a text, or stop by. You are not bothering anyone. In fact, you are helping more than you may ever know. You are offering continued hope for someone who is grieving. It is easy to offer help right after a tragedy, but as you go back to your ‘normal’ lives and schedules, don’t forget those who are not as fortunate to be able to do the same. Remember them in two weeks, one month, three months, even six months from now. When you reach out, don’t just ask, “what can I do to help?”, be specific. Ask what they need for dinner. Ask if they need help with dropping or picking up their children from school. Ask if they need to borrow one of your vehicles. Ask if you can do their laundry. Ask what they need from the grocery store. Instead of answering a general question with “we’re ok”, they will be able to tell you what their continued needs are without feeling like a burden to others.

Examine Your Mindset

If you’re ruminating on the difficulty and pain caused by Harvey without being able to take steps forward, this may be a sign that you’re getting stuck. Start to challenge your thinking so you can move toward your goals.

Avoid seeing the problems as insurmountable. It can be easy to feel overwhelmed with the logistical steps needed to move forward after Harvey. If you find that you’re getting stuck because the problems seem too large to handle, take a step back and re-evaluate. Set realistic goals for yourself. Also try breaking each goal into small, digestible pieces that do not feel as overwhelming. For instance, submitting an insurance claim for flood damage can be a huge undertaking…but there are ways to make it feel less overwhelming. Break the task into smaller components–call your insurance company to find out their process for submitting a claim, separate items to be photographed into small groups, photograph items within each group, complete your claim forms, etc. If you find that you get stuck on a task, ask yourself, “what is the smallest step I can take today to move toward this goal?”

Notice how challenging avoidance helps you to feel better.  As you start to build momentum toward solving the tasks ahead of you, your sense of accomplishment will increase. Research shows that engaging in activities that give you a sense of accomplishment boosts mood and counteracts feelings of depression or sadness.

Take a news break. Oftentimes, the media covers the worst case scenarios, which can skew your mindset on what’s really happening for you. If you find that watching the news is making you feel worse or is keeping you from taking steps forward, take a break from it. Either focus your energy on taking care of yourself or on solving a problem ahead of you. Those are actions that will help you to feel better.

Accept the circumstances that cannot be changed. Not every problem is solvable. There are likely circumstances that have occurred due to Harvey that don’t have clear solutions. For instance, you may have lost special photographs or prized possessions as a result of the flood damage. Items like these are not exactly replaceable, and that is truly painful. Acknowledge that pain and grieve what was lost. Ultimately, allow yourself space to heal and focus on what you can control.

Be Kind to Yourself

This is a difficult time, and it is especially important to focus on taking care of yourself.

Look for opportunities of self-discovery.  Connect with your values and what is really meaningful to you in your life. Oftentimes, significant life events cause people to examine their lives in new ways and to get more connected with what really matters to them. Take this time to learn more about yourself. Perhaps you are passionate about your environment or community, or you want to reconnect with friends and family, or maybe you want to enroll in a course or training on an area of interest. Get connected with what really matters to you.

Be self-compassionate. Dealing with the aftermath of Harvey is difficult and stressful. Be kind to yourself by acknowledging how hard it is and by comforting yourself. Try treating yourself as you would treat a close friend or loved one going through a hard time. Let yourself know that “you’re doing the best you can” or “today was difficult, but you’ll get through this challenge.” Check out this website for some guided meditations, self-compassion exercises, and information on self-compassion from its leading researcher (**link**).

Get engaged in healthy coping behaviors. Although it may be difficult right now, try to focus on eating a balanced diet, drinking water, exercising, regulating sleep, and doing meditation or other relaxation techniques known to help manage stress. Also think about using other healthy coping strategies that have worked for you in the past, because those are most likely to benefit you now. Avoid drinking alcohol or doing drugs to cope, because they are depressants and can de-motivate you for taking steps toward meaningful goals.

Develop or re-engage in a routine. Your routine has been disrupted due to Harvey. Do your best to move forward by creating some routine structure to your day. Our brains love predictability and structure, so create that for yourself. Try to wake up and go to sleep at a regular time each day. Establish certain things you want to do on a daily or weekly basis. Ideally, include some healthy coping strategies (i.e. taking steps toward goals, taking care of yourself, doing things you like to do) as part of your routine.

Get Support from Professionals

If your emotional reaction to Harvey is above and beyond what would be expected OR your symptoms of distress last longer than 6 months, getting help from a professional is likely warranted. Look into options for support groups or individual therapy in your community. If you’re interested in joining a support group, try to find one that is facilitated by psychologists or other trained professionals. Similarly, if you’re interested in individual therapy, try to find psychologists or trained professionals who use evidence-based approaches in their work. Recommended approaches include cognitive behavior therapy (CBT), dialectical behavior therapy (DBT), acceptance and commitment therapy (ACT), solution-focused therapy, and problem-solving therapy. Depending on your symptoms and areas of concern, it may also be helpful to find a therapist specializing in grief and loss or trauma. You can find psychologists near you by contacting the Texas Psychological Association:

Ways to Seek (or Provide) Support through Organizations

In addition to these coping strategies, numerous organizations throughout the greater Houston area are available to provide resources and help move Houstonians toward regrowth. Research also shows that helping others can have a profound impact on health and happiness (Dunn et al., 2008; Post, 2005). The following are a few of the resources available, whether seeking support for yourself and family, or providing it for others.

To find a shelter, call 800-RED-CROSS or visit:

For food assistance, contact the Houston Food Bank at 832-369-9390 or visit:

To find family and friends or to register yourself as safe, visit the American Red Cross at:

To report a missing child, contact the National Emergency Child Locator Center at: 1-866-908-9570

To search for a lost pet, contact the Houston SPCA at:

To apply for disaster assistance, call 1-800-621-3362 or visit:

To donate to the Hurricane Harvey Relief Fund, established by Mayor Sylvester Turner, text HARVEY2017 to 91999 or visit:

Finally, if you are unsure where to donate, the following website is an excellent resource as it rates charities based on transparency, accountability, financial health, and overall effectiveness at distributing donations:

Coming Together with Hope and Healing

This is a difficult time right now, and it will take time and effort to heal. We’ve provided some evidence-based suggestions for moving forward with the healing process. All in all, focus on what you can control, seek out support, and continue to take steps toward solving problems and taking care of yourself. Evaluate what’s working and what’s not working so you can continue to work toward your ultimate goals. This is a time for connection and growth. This is a time for healing and hope.


This article was adapted from American Psychological Association (APA) and Texas Psychological Association (TPA) disaster relief resources:

Other Resources

Boon, H. J. (2014). Disaster Resilience in a Flood-Impacted Rural Australian Town. Natural Hazards, 71(1), 683-701.

Dunn, E. W., Aknin, L. B., & Norton, M. I. (2008). Spending money on others promotes happiness. Science, 319(5870), 1687-1688.

Post, S. G. (2005). Altruism, happiness, and health: It’s good to be good. International Journal of Behavioral Medicine, 12(2), 66-77.

Common Myths and Misconceptions about Trichotillomania: Part 2 Functions of Pulling and Treatment

By Hannah Sommer Garza, Ph.D.

Welcome back to the second part of our two-part series on myths and misconceptions about trichotillomania from a trichotillomania treatment provider. If you missed Part 1, check out our previous post ( ) on myths about what trichotillomania is, who experiences it, and why. Today’s post will focus on misconceptions about reasons for pulling behaviors and how trichotillomania is treated. The hope with this two-part series is to dispel some common myths and misconceptions about trichotillomania, to pass along up-to-date information, and to reduce stigma associated with the lack of awareness about trichotillomania and trichotillomania treatment.

As a reminder of some of the basics, trichotillomania is also known as hair-pulling disorder, TTM, or “trich.” It involves the recurrent pulling out of one’s own hair despite attempts to stop pulling. It is considered a Body-Focused Repetitive Behavior (BFRB), similar to other behaviors like skin-picking and nail-biting. Now let’s keep dispelling some of these pesky myths.

Myth:  People with Trichotillomania are Pulling to Get Attention

This couldn’t be further from the truth. Often due to feelings of shame and embarrassment, many individuals with trichotillomania go to great lengths to hide their trich from others. In reality, the majority of people with trichotillomania attempt to REDUCE attention they receive related to their trich, not get more of it. Furthermore, research has shown that pulling can occur outside the individual’s awareness (also known as “automatic” pulling). It is not being used as some sort of manipulative strategy to get attention from others.

Myth:  Trichotillomania is a form of self-harm

The big take-home here is that it’s all about function. For individuals with trichotillomania, the intention of the pulling is NOT to hurt oneself. In contrast, that is the intention for self-harm. The injuries or damage caused by hair-pulling are merely a result of pulling and not the goal of pulling. Furthermore, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) distinctly categorizes self-harm as separate from trichotillomania, using language like “the behavior is not better explained by another mental disorder or medical condition (e.g. trichotillomania).” Trichotillomania is specifically mentioned in the DSM-5 as a rule-out for self-harm, implying that they are distinct from each other.

Functions of trichotillomania pulling are usually sensory related (e.g. seeing a hair out of place, or feeling discomfort with a coarse hair), emotionally related (e.g. pulling more when feeling nervous, bored, or stressed), and/or cognitively related (e.g. “I will just pull one more” or “pulling this eyebrow hair will ‘fix’ my brows”). The function of NSSI pulling is to harm oneself.

Myth:  People with Trichotillomania can “Just Stop”

This myth always reminds me of a comedy sketch with Bob Newhart called “Stop It” ( It’s a parody of a therapy session, where the provider’s treatment for the patient’s concern (not trich-related) is to “just stop it.” As you can imagine, it’s over the top, not very therapeutic, and has no impact on helping the patient to “stop” her unwanted concern. All silliness aside, I imagine that this is what many people with trichotillomania experience when people tell them to “just stop” pulling. It’s just not helpful.

Many factors can influence pulling to make it a difficult behavior to change. Researchers suspect a genetic component, as many BFRBs cluster together within families. Overriding genetics is no easy task without evidence-based techniques for doing so. Additionally, people with trichotillomania often describe an enjoyable/soothing/calming sensation that occurs during pulling. I often think of it as similar to eating chips and queso (my great diet weakness). I may be very consciously aware that I am breaking my diet as I continue to reach for chip after chip after chip after chip…but boy do they taste good in the moment! The long-term effects of pulling are very difficult to keep in mind when the body is experiencing immediate “rewards” while pulling. Trichotillomania treatment involves the patient and therapist working together to identify targeted ways to prevent and manage urges for pulling. It takes a lot of work to change a behavior like pulling, and saying that the person can “just stop” is extremely invalidating.

Myth:  Once with Trich, Always with Trich

Trichotillomania is a Body-Focused Repetitive Behavior (BFRB; ). Other common BFRBs include skin-picking (excoriation), nail-biting (onychophagia), and knuckle-cracking. Evidence suggests that it is not uncommon for individuals to change target BFRBs throughout development or to engage in multiple BFRBs simultaneously. For instance, someone may start pulling eyebrows as a child, then focus more on chronic skin-picking during adolescence and early adulthood, and may even shift back to trichotillomania during adulthood. Researchers are actively attempting to unveil reasons for these shifts.

Approximately 23% of people with trichotillomania have a relapsing and remitting course of symptoms with at least one period of complete symptom remission, according to a retrospective report study (Meunier, Tolin, Diefenbach, & Brady, 2005).

Another way trichotillomania can change for a person is through trichotillomania treatment. Will a flip be switched and the urges disappear? Unlikely. This is why learning skills in treatment for how to prevent and manage pulling urges is a powerful way to change pulling behaviors.

Myth:  All Treatments are Created Equal

The Trichotillomania Learning Center’s Scientific Advisory Board, a panel of expert clinicians and researchers, have identified specific behavioral treatments ( ) that have evidence for treating trichotillomania. Specifically, Cognitive Behavioral Therapy (CBT) and its related therapies are recommended.

CBT is a type of therapy that involves an identification of problematic thoughts, feelings, and behaviors, and a focused training in how to make them more helpful. For more information on CBT, check out our former blog post ( ). Several treatments fall within the umbrella of CBT treatments, including Habit Reversal Therapy (HRT), Comprehensive Behavioral Treatment (ComB), Dialectical Behavior Therapy (DBT), and Acceptance and Commitment Therapy (ACT).

If you or a loved one are seeking treatment for trichotillomania, be on the lookout for words like “cognitive behavioral therapy (CBT),” “behavior therapy,” “habit reversal,” “third wave treatments,” “dialectical behavior therapy (DBT),” or “acceptance and commitment therapy (ACT).” The provider should also be familiar with body-focused repetitive behaviors and the Trichotillomania Learning Center. If they’re not using some language like this, then they may not be best trained to provide trichotillomania treatment.

Although the main treatment for trichotillomania is CBT, medication can also be helpful. There is no one medication that works for everyone with trichotillomania, but some medications have been found to reduce symptoms for some people. Medications are often used to relieve emotional symptoms that may be related to pulling for some people. Selective Serotonin-Reuptake Inhibitors (SSRIs) are often used to address symptoms of anxiety and depression that may be associated with pulling. There is preliminary support for N-Acetylcysteine (NAC), an amino acid working on the glutamate system ( to reduce trichotillomania symptoms. Over 50% of individuals in the cited trial found significant improvement in trichotillomania symptoms over the course of 12-week NAC treatment. However, to date, no medication has been approved by the Food and Drug Administration (FDA) for the treatment of trichotillomania or other BFRBs. Scientists are working to better understand trichotillomania and to enhance its treatments. Check out this website ( if you’re interested in learning more about the research initiative.

Other treatments do not have enough research support to be currently recommended by trichotillomania experts as stand-alone treatments. This includes approaches such as hypnosis, diets, massage, acupuncture, and electric stimulation.


I’m hopeful that this two-part blog series on myths and misconceptions about trichotillomania has been helpful, and that you can help to spread the truth about trichotillomania and its treatment. The unfortunate truth is that there is still a lot that we don’t know about trichotillomania and its successful treatment. If you’re at all interested in learning more about the research initiative or even getting involved in a study near you, I encourage you to check out the website linked above. For more information about trichotillomania, you can also check out the Trichotillomania Learning Center (TLC) Foundation for BFRBs (


American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (5th Ed.; DSM-5). Washington, DC.

Grant, J. E., Odlaug, B. L., & Won Kim, S. (2009). N-Acetylcysteine, a Glutamate Modulator, in the Treatment of Trichotillomania:  A Double-blind, Placebo-Controlled Study. JAMA Psychiatry, 66(7), 756-763.

Grant, J. E., Stein, D. J., Woods, D. W., Keuthen, N. J. (2012). Trichotillomania, Skin Picking, and Other Body-Focused Repetitive Behaviors. Washington, DC, London, England: American Psychiatric Publishing Inc.

Meunier, S. A., Tolin, D. F., Diefenbach, G. J., & Brady, R. E. (2005, November). Severity and course of hair pulling symptoms across the lifespan. Paper presented at the Annual Meeting of the Association for Behavioral and Cognitive Therapies, Washington, DC.

Woods, D. W. & Houghton, D. C. (2014). Diagnosis, Evaluation, and Management of Trichotillomania. Psychiatric Clinics of North America, 37(3), 301-317.