Transcript of 17th Session between Charles Balis, M.D. and Ms. Rachel Tanner, Friday, September 11, 1998 at 3:00 pm.

Ms. Tanner: Hi.
Dr. Balis: Hello, Rachel. Please sit down. Hmm. Are you okay?
Ms. Tanner: No, I'm not. I'm sinking. I'm in deep again, and I don't know how to get back out. I'm sorry. I'm not making much sense.
Dr. Balis: You are making enough sense for me to know that you're struggling hard with OCD again. I'm sorry I had to miss our last appointment. What's going on, Rachel?
Ms. Tanner: Where should I start? Carla and I aren't seeing each other anymore. Maybe it was inevitable. Remember when I asked, "What if she dumps me?" I guess I kind of knew even then that it might not work out. Maybe I couldn't give her enough of what she needed, or she got tired of waiting. Maybe the novelty wore off. But there are other things going on, too. My grandmother and I have been at odds with each other since she returned from Germany.
Dr. Balis: I want to go back to Carla for a moment. Do you feel like you got closure with that relationship?
Ms. Tanner: What do you mean?
Dr. Balis: Did you and Carla come to an understanding as to why you won't be seeing each other?
Ms. Tanner: I just told you why.
Dr. Balis: Yes, but it sounded as if you weren't sure.
Ms. Tanner: Oh, I'm sure. I'm sure that I have sexual limitations. I'm sure that she's going to replace me as soon as she finds a new guinea pig. I'm sure that I'll be reminded of my failure every time I see her or hear her name.
Dr. Balis: Rachel, I'm going to take each of the issues you just mentioned and turn them around to give you another way of looking at them. First, instead of thinking you have sexual limitations, remember that you were able to explore intimacy and gain trust with a lover. The last I heard, you were enjoying the physical relationship with Carla.
Ms. Tanner: There were things I couldn't do, though.
Dr. Balis: Yes, but let's focus on what you were able to do. You also mentioned Carla finding someone new. I'm quite certain that, in time, you'll find someone new, too. Carla could have been your stepping stone in exploring intimate relationships. The experience you gained with her will help you in the future.
Ms. Tanner: That's a thought that horrifies me at the moment.
Dr. Balis: I understand, but that will change. I promise. I also want you to be very clear that you didn't fail in this relationship. You triumphed in many ways. You explored intimacy, developed trust, revealed your OCD to a new person, and you got a lot of enjoyment out of the experience.
Ms. Tanner: But it hurts like hell right now.
Dr. Balis: There is a good expression: "Suffering is the great motivator of growth." It might hurt now, and you might feel like you're in a tailspin, but that's what most of the songs and poems ever written are all about. Most people feel bad when a relationship ends. It's not just your OCD that makes you feel bad.
Ms. Tanner: No pain, no gain?
Dr. Balis: Exactly. And your ability to see a lighter side in the midst of tough times is refreshing.
Ms. Tanner: I amaze myself, too, but not in ways that you'd agree with. I'm amazed that I put myself in a vulnerable position. And now I have to pay for my stupidity.
Dr. Balis: You have to learn to see the positive results of this relationship.
Ms. Tanner: I'm sorry. It's not that I really feel stupid. It's just that I need a way to stop from feeling used. I feel so naive. I guess I need to learn from my mistakes.
Dr. Balis: Hmm. What would you want to change if you could?
Ms. Tanner: I might have slowed down. First, we have a couple of beers, and the next thing I know, she's in my pants...or in my swimsuit, to be precise. But I have to admit, it felt good getting carried away.
Dr. Balis: That's what I'm looking for, Rachel. It felt good--that's a positive way of looking at this experience. Stepping stones, not quicksand.
Ms. Tanner: Doctor Balis, this is all well and good to be sitting in your office, saying the right things, processing on a cerebral level. But what do I do when I start stewing about it at home? Look at this.
Dr. Balis: Oh no. I'm sorry. I should have been there for you. You could have told my service, and they would have gotten me in New York. I...
Ms. Tanner: It's too late. I was sort of in a trance. Pretty ugly, huh?
Dr. Balis: I didn't notice your hair until you pointed it out.
Ms. Tanner: I have a lot of experience hiding my bad habits.
Dr. Balis: Pulling your hair out like that is not...
Ms. Tanner: Whatever. Part of the problem is that school was out for the Summer, and I had too much time on my hands, so to speak.
Dr. Balis: Do you remember what lead up to the hair pulling? What thoughts did you have prior and during?
Ms. Tanner: I was just sitting at my desk. I'd been playing Hearts on the computer, when I started thinking about how it was so much work to try to be normal. I felt deserted--no school, no Carla, no more solitude, no job. And then I started to think about all the things I wasn't able to do in my relationship with Carla. Maybe I didn't deserve to be with someone. I still wonder if I was too selfish. Whew! True confessions.
Dr. Balis: Hmm. And when did you realize that you were pulling your hair out?
Ms. Tanner: Well, I consciously stopped for a moment to get out my journal. I opened it up to a blank page and actually tried to come up with some things to write down to divert myself from negative thinking.
Dr. Balis: That's good.
Ms. Tanner: But I got writer's block and started thinking and pulling again.
Dr. Balis: Hmm. What did you do with the hair you pulled out?
Ms. Tanner: I looked at it, found the end with the root, and then--this is going to sound really weird--and then I pressed it onto a piece of paper using my fingernail. I "glued" it to the paper at one end. Eventually, I had lined all the hairs up in rows.
Dr. Balis: Hmm.
Ms. Tanner: That's what I used to do before, only I worked in front of a mirror and stuck them to the mirror. When I was done, I pulled them off, folded them in a piece of paper, and tossed them. When I'm in front of the mirror, I can see the gray hairs and the wiry ones. Those are the ones I'm after--the less than perfect ones.
Dr. Balis: But your hair loss is all in one area, above your temple.
Ms. Tanner: Yeah...
Dr. Balis: Rachel, have you pulled hair from other places?
Ms. Tanner: Well, yes.
Dr. Balis: Hmm.
Ms. Tanner: My pubic hairs were all gone a while back. But you're the only one who knows about that.
Dr. Balis: So you are not aware of the moment you start to pull your hair. Did you try to stop when you realized what you were doing?
Ms. Tanner: Yes. The attraction of pulling is hard to describe. It feels cleansing, in a way. Maybe subconsciously, it's like lightening my load, hair by hair. Also, I'm trying to get rid of imperfection--the imperfect hairs. There's definitely a pleasurable sensation that goes along with it. Even the prickle of a hair root popping out is satisfying somehow.
Dr. Balis: Thank you for giving me the details. I know you see the drawbacks in succumbing to the desire to pull out your hair. We need to get you back on track. I see this is a temporary reaction--because your relationship with Carla ended, and because you had extra time, you somehow found comfort in an old ritual. But I think I have some ideas on how to help you.
Ms. Tanner: Are you going to increase my meds?
Dr. Balis: I don't think it would be an effective option at this point. No, my proposal is going to require more work than that but I think it could be more effective.
Ms. Tanner: I'm listening.
Dr. Balis: Your hands are a big part of how you express your OCD. They are almost a weather vane, telling of an approaching storm or clear skies. We need to find something for your hands to do while your mind wonders that's a lot less destructive than pulling your hair out. We need a constructive activity to keep your hands busy.
Ms. Tanner: Like what?
Dr. Balis: In many cultures, people carry beads or stones in their pockets to play with when they worry about something--the worry stones. There are other things that work to the same effect. Here's one.
Ms. Tanner: A Koosh ball?
Dr. Balis: The one and only. But a tennis ball, stress ball, or even Silly Putty would work. You knead it, squeeze it, manipulate it instead of pulling your hair.
Ms. Tanner: That could work at home, but what about in public?
Dr. Balis: A rabbit's foot on a key chain, quarters in your pocket, knots in a hankie, even twisting the ring on your finger are all ways to transfer agitation. Smoking is the classic example, but I'm not going to recommend that.
Ms. Tanner: Choke! I guess I can try something like that. I like the texture of those gummy plastic toys that are so abundant now. I played with them before. They are kind of icky, though. But if I am not aware of the moment when I start to pull, how do I stop myself and transfer that energy into a worry toy?
Dr. Balis: You mentioned that you sat at your computer one time you started, and you used to pull hair in front of a bathroom mirror. The idle times are probably when you are most vulnerable. Your mind drifts, and before you know it, your hand is in your hair. If you always try to have a purpose before you sit down to relax, you might be able to decrease the down time. When you finish an activity, get up and move on to your next purposeful act. Also, try to have the replacement items nearby. Have several of them to turn to when you need them.
Ms. Tanner: A whole arsenal of new toys.
Dr. Balis: It will require a conscious effort. Awareness is the first step. One day at a time.
Ms. Tanner: You sound like you are reading bumper stickers.
Dr. Balis: Sorry for the clichés. You do know what I mean, don't you?
Ms. Tanner: Yes.
Dr. Balis: One more thing, you can make your hair unavailable.
Ms. Tanner: Shave?
Dr. Balis: That may sound extreme, but some people with trich do resort to a that option.
Ms. Tanner: Trick?
Dr. Balis: Trich. Trich is short for trichotillomania, the act of hair pulling.
Ms. Tanner: That's weird. I didn't know there was a name for it.
Dr. Balis: Scientists like to name everything. But you can wrap your hair up or tie it back. You can put it up into a towel during the times when you are at your computer.
Ms. Tanner: I was only wearing this scarf to cover up the bald spot, but I guess I can wear it to protect myself.
Dr. Balis: That's it. And I want you to notice something for our next session. Pay attention to the thoughts you're having that lead to the desire to pull. Also notice if you feel tension while resisting the urge to pull. Tell me for how long you were successful--days, hopefully, but time may go slowly because I've asked you to focus on this one thing.
Ms. Tanner: I haven't had homework for awhile.
Dr. Balis: When does school start up again?
Ms. Tanner: Next week. I'm starting to lose the motivation. But I'm afraid of what I'll become, if I don't go to school.
Dr. Balis: You seem to be at your best when you are busy. I encourage you to continue school, yoga, swimming, writing. Perhaps you can take up knitting. That's a good busy hands activity and productive, too. And didn't you say you play the piano?
Ms. Tanner: I can, but I don't.
Dr. Balis: It seems like a perfect activity for those hands.
Ms. Tanner: I'll think about it. The piano is just sitting there collecting dust.
Dr. Balis: So, which of my suggestions are you going to try?
Ms. Tanner: I don't mean to be disrespectful, but my grandmother is paying you big bucks, and you are sending me away with a prescription for Koosh balls, a buzz cut, and a rabbit's foot? What's up with that?
Dr. Balis: I thought you understood...
Ms. Tanner: Hold on to your doctorate! I'm just kidding! Seriously, every time I meet with you, I feel like there is a shred of sanity left in me. I take your input to heart. It's like in yoga classes, the instructor can make an adjustment or say something in a way that makes me understand the pose just a little better. Some of the things you say I replay over and over. You've really helped me.
Dr. Balis: You almost had me there. I appreciate the feedback, Rachel. I don't always feel successful.
Ms. Tanner: Especially considering my record!
Dr. Balis: Rachel...
Ms. Tanner: I know, be positive. It's my weird humor coming out.
Dr. Balis: So, I'll see you in two weeks?
Ms. Tanner: I look forward to it.
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