PSYCHOTHERAPY WITH A 3 YEAR OLD CHILD SUFFERING FROM TRICHOTILLOMANIA – A BRIEF THERAPY APPROACH
Psychotherapy with a 3 year old child suffering from Trichotillomania (hair pulling) associated with Trichophagia (chewing and consuming the hair) – A Brief Therapy Approach
This article will attempt to show how a very worrying habit exhibited by a 3 year old girl was effectively treated psychologically by using a Strategic approach, a psychological intervention which does not require elaborate discussions looking for meanings or insights – something very difficult to do with a child of this age.
It should noted that the following details have been prepared so that the family’s anonymity is maintained.
I initially saw the whole family and their childminder together in a family session, after they were referred to me by Dr David Fenton, Consultant Dermatologist, who has been referring patients to me for some years. David is an outstanding specialist in hair and skin difficulties, and as well as the medical interventions such as hormonal imbalances; he is also very aware of the psychological factors in many difficulties such as pattern baldness amongst other difficulties encountered by his patients.
Hazel was a very bright 3 year old, living with her successful professional parents. She had a little brother aged nearly 1, and they were both looked after by a childminder during the day when her parents were at work, who as well as providing pastoral care was also encouraged to engage in some light educational programmes with the children.
It was immediately clear that Hazel’s parents were very ‘hands on’ and involved with their children. The parents, for example, shared the bedtime rituals and spent a lot of time at the weekend with the children doing various activities. There was also plenty of input from the grandparents when it was logistically possible for them to see the family.
From my observations and from what they told me, the parents seemed to have a happy and fulfilling relationship.
Hazel seemed to have made the adjustment to having a brother very positively, and indeed it was my impression that they were very close to each other.
There was, therefore, very little evidence of any underlying family psychopathology.
It was therefore quite exasperating for her parents that Hazel had ‘from an early age’ been pulling her hair from her scalp as well her eyebrows. According to her GP, this activity was originally seen as a form of ‘comforter’. This would happen any time during the day, but was most likely to occur during the night.
While there were cosmetic concerns because of the ugly bare patches which had appeared on her head, there was also the more serious concern that as she was consuming a lot of the hair that she pulled out, and that this could cause serious health problems as she started to line her stomach with the hair.
According to the DSMIV-TR this condition is very often associated with high levels of anxiety, and consequently when treating adults and older children the first step would be to implement an anxiety management programme where various exercises will be taught to the anxious individual, and attempts will be made to look for the causes of the anxiety and try and alleviate them, often through family therapy processes.
In Hazel’s case there seemed to be little sign of anxiety, and indeed she was able to handle her sessions with me with or without the bulk of her family, and there generally appeared to be very little anxiety in the family as a whole, apart from their concerns about her hair pulling.
The family had tried all of the most commonsensical approaches to try and break the destructive habit. This has included simple attempts to get her to understand the consequences of her behaviour, various sanctions and rewards to disrupt the behaviour.
None of this had had any long term positive effect, and so it would have been clearly a waste of therapeutic time to go over the same approaches again.
While it was helpful to see the whole family initially to make a general assessment, because there were no obvious family difficulties I decided it would be best to treat Hazel individually with just one member of the family system present, both as a chaperone and also to provide information to me about her progress, and to help with the task that she was given.
I had learned these techniques from my time at The Family Institute in Cardiff during the 1980s. The Institute was a project set up by the charity Barnardos with the first principal being Sue Waldron-Skynner.
By the time I succeeded her, the Institute had acquired some outstanding family therapists, in particular Brian Cade, Philippa Seligman, Peter Hudson and Bebe Speed, who were working with what were, at that time, unique innovations such as one way screens, where part of the team would sit and observe the session, and phone in any interventions that they thought were necessary. It also allowed a team to observe the session, video recording it to analyse the session later. These techniques were excellent aids to teaching students, a role that the Family Institute thought was very important, and indeed the Institute played a major contribution towards the spread of Family Therapy techniques in the UK and elsewhere.
Brief Therapy was a major innovation in the 1980s and arose from the pioneering work by some outstandingly creative therapists in the US, including Jay Haley and Milton Ericson. The Family Therapy team, led by Brian Cade, further developed this work leading to some outstanding publications.
The strategic approach to Brief Therapy can perhaps be best exemplified by a very famous intervention by Ericson. He was working in a psychiatric establishment where traditional psychotherapeutic techniques had had limited success and psychotropic medication for psychotic behaviour was not as advanced as it is now. There had evidently been an attempt by the hospital staff to get a psychotic man with a delusion that he was Jesus to become involved in the hospital therapeutic programme. He had refused to enter into a woodworking programme until Ericson took him aside and said, ‘I believe you have had experience with carpentry’. ‘Jesus’ had some difficultly denying this and consequently joined the therapeutic programme.
I find this to be an exquisite intervention which has to involve a lot of what is known as ‘right brain’ or ‘creative brain’, where there is less employment of the ‘left brain’ or ‘conscious insight brain’.
For the therapist it is very pleasurable when one of these interventions ‘pops up’, and of course it does not happen every day.
If an intervention of this sort works, then the first rule is not to allow any form of intellectual analysis about how it may have worked.
Treatment of Hazel
During my session with Hazel I discovered, during the course of conversation with her and her mother, that she was very keen on a Walt Disney film, ‘Frozen’. This feature length cartoon involves two sisters who live in a typical Walt Disney world. Anna is a ‘snow queen’ and Elsa is some sort of princess, who very conveniently has a beautiful head of hair, not dissimilar to Hazel’s.
Hazel had an Elsa doll, who in the cause of science I slandered by suggesting that she was pulling out her own beautiful hair. I tasked Hazel with having to look after Elsa’s grooming, which I suggested might be difficult because she had the unfortunate habit of pulling her hair out. It was Hazel’s job not only to make her doll look presentable, but also find a way to see if she could cut down on the hair pulling.
Hazel brought in the Elsa doll to the next two or three sessions and reported that while it had been something of a struggle she had managed to get Elsa to behave herself and her hair was now no longer being molested.
Her mother, who also attended the session, indicated that Hazel had also stopped pulling her own hair.
After six sessions her therapy was ended, with Hazel promising to keep a close eye on Elsa, particularly to make sure that her hair was well groomed.
Apart from congratulating Hazel on her outstanding parenting of her doll, no comment was made about the specific issues of hair pulling in either case.
The family was also asked not to do any form of analysis around the hair pulling.
I followed the family up three years later and discovered that Hazel had maintained a ‘no hair pull policy’ and that Elsa had done the same. Unfortunately Hazel was no longer interested in Elsa because she had evidently moved on from dolls.
Again, no comment was made on my part about the changes.
It would seem that this simple strategic intervention had had a profound effect in changing Hazel’s behaviour in a way that has persisted now for three years.