Shaindy was a sister-in-law of Rebbetzin Schmidt, the director of a seminary in Beit Shemesh where I’d given a few workshops. “I’m the only one she’s told about the problem, Dr. Freedman,” Rebbetzin Schmidt told me. “Everyone else thinks there’s some kind of medical condition going on, but unfortunately, I know better.”

“Could you give me some kind of hint to you sister-in-law’s problem, Rebbetzin?” I asked.

“You’ll see immediately, Dr. Freedman,” she responded. “Just keep in mind that she’s not crazy or anything like that. She’s just got this weird thing with her hair.”

“She pulls it out and eats it?”

“Dr. Freedman! Are you some kind of prophet?”

“Nope. Just a good guess.”

I’d seen my first case of trichotillomania back as a medical student when I was considering going into psychiatry. I remember working on the pediatric surgical service and being called to the bed of a young boy whose small intestine was blocked with a trichobezoar: a wad of half-digested hair that he’d swallowed piece by piece after tearing it out of his head.

I’ll never forget the surgeon patting me on the back after the operation to remove the obstructing blob of hair and saying, “You’re gonna be busy with all sorts of interesting things as a psychiatrist.”

“What do you mean, Dr. Hirsh?”

“I mean that all I have to do is remove this kid’s hairball. You’ll have to stop it from happening again.”

Shaindy was a very put-together young woman who was waiting for me outside of my office, wearing a pound of makeup and a $3,000 sheitel. Had I not been familiar with her story, I would have thought she was a newly-married woman who had splurged on an expensive wig. With the knowledge of her condition though, it was clear that she was covering up the hair-pulling disorder that had caused her to pluck out her eyebrows and eye lashes — thus the overkill on the eyeliner — and most of the hair on her scalp, which she covered up with a good custom wig.

I invited Shaindy into my office and offered her a cup of tea to try and relax. She was clearly embarrassed about the issue at hand as she nervously accepted.

I didn’t get too much of a response after introducing myself, until I mentioned Rebbetzin Schmidt.

“She was the one who told me I should come to see you,” Shaindy acknowledged before looking away again.

I started to speak, when Shaindy burst into tears. I handed her a box of tissues and gave her a few minutes to cry through the crushing weight of her secret.

“I’m not crazy you know. I mean, I know it sounds crazy, but I’m not crazy,” she said between sobs.

“What makes you think you’re crazy?” I asked.

“Well, for starters, I pulled out all of my hair, and I eat it. Since when is that normal? I must be the craziest person around.”

“Not even by a long shot.”

Shaindy laughed nervously, “But I’m still crazy, I mean, look at this!” she said as she ripped off her sheitel and revealed a nearly-bald scalp. “This isn’t crazy?!”

“This isn’t stam crazy, this is trichotillomania,” I responded calmly. “It’s a well-known disorder, which means you’re in good company. And, if you don’t mind me saying, the only ‘crazy’ thing is pretending that this will go away on its own. But if you want to get better, I just want to warn you that this is going to be a real ‘lefum tzara agra’ type of avodah.”

Shaindy settled herself and put her sheitel back on. She straightened up and wiped away her tears before saying, “I know it won’t be easy, but can you fix this for me?”

“Nope. But I can help you fix this for yourself.”

“Okay, I mean, what do you mean, Dr. Freedman?”

“I mean that I can teach you how to beat this, but it isn’t the kind of thing that simply taking a pill every morning will cure.”

“I get it. I guess I’m pretty motivated, I mean I’m never going to get married like this. So what should I do?”

I proceeded to explain some basic principles of cognitive behavioral therapy for Shaindy’s specific condition. We discussed the neurological basis of anxiety and linked her hair-pulling behaviors to an internal feeling of distress. I also suggested she take a certain anti-depressant, which, together with therapy, has been shown to effect positive results.

I encouraged Shaindy to discuss her thoughts throughout the entire hair-pulling process. She began to describe how it began with a feeling that there were thicker hairs and thinner hairs, questions of texture in the hair, some with tiny knots, and some that were longer or shorter than others. She would then touch each hair until she found a “good one.”

“Yes, a good one, I know it sounds crazy, but a good one is a rough, long, and knotted one that basically needs to go, or I’m totally paralyzed.”

She would then pull at it a few times before yanking it out completely. After that she would lick it and then stuff it into her mouth, chew on it, and swallow it whole. At this point she’d have a sensation of calm and ease, feeling that she was “done” — until the craving to pull came again.

“Do to still think that I’m not completely crazy?”

“I’m entitled to my own opinion, but right now, we need to talk business. We need to track the physical sensations that come as you get ready to pull out your hairs. We need to find out when your heart starts racing, when your chest gets tight, and then stop the train in its tracks before it gets too much momentum.”

“It’s a bit scary, thinking about stopping. Maybe I won’t be able to cope? And anyway, tachlis, what am I supposed to do?”

“You’ll take a tiny journal and keep it in your pocket. In the journal, you’ll rate your desires for hair-pulling three times each day — erev, vaboker, vetzaharayim — as well as every time you have a specific yetzer for plucking out your hair. By staying mindful, and taking the emotion of anxiety and appealing to your rational side as you write all of this down in a calculated fashion, you’ll be able to conquer this.”

Shaindy understood the general principle, and we made a time to meet the following week to check on her progress.

When we sat together for a second time, Shaindy was pleased to show me her journal. “The cravings are much less, Dr. Freedman, and I know it’s only a few days but I feel like I’m getting a handle on this.”

We added a few new concepts to the treatment, and Shaindy even smiled as we finished the session, with a plan to check back the following week.

“Dr. Freedman?” Shaindy asked as she gathered her things. “Is there a reason I have to do this work at least three times a day? I mean, even when I’m cured and doing better?”

“Absolutely.”

“I mean, you davka said ‘Erev vaboker vetzaharayim.’ Just like tefillah.”

“Exactly.”

“Oh... I get it then. I need to daven to get better?”

“Davening and hishtadlus. It’s the recipe for a happy and a healthy life no matter what ails you. Listen Shaindy, you’re not cured. There are going to be ups and downs.”

“What do you mean?” she replied somewhat despondently.

“I mean that just like with everything else in life, there are speedbumps. Stressful times are certainly going to increase the urge to pull out your hair, and it might even be that we’ll adjust the medication, depending on how things are going.”

Shaindy reverted to looking down at the floor as she nodded her head in half-surrender and half-agreement as I continued, “But Geulah comes slowly. And not to belabor the metaphor, but just like redemption sprouts, so will your hair, b’ezras Hashem.”

Shaindy looked up with the first hint of a smile. “And I can save this sheitel for when I get married, b’ezras Hashem.”

“Bekarov Etzleich!”

Identifying details have been changed to protect the privacy of all parties.

Goodbye Letter

Dear Readers,

Over the last 25 months, I’ve had the tremendous honor of spending each and every week with you, sharing some of what happens on my proverbial “couch.” I’d been toying with the idea of writing a column like this for a long time and am truly grateful to the editors at Mishpacha for giving an often-eccentric and iconoclastic column on the practice of psychiatry a shot. With the help of my amazing editors (Mrs. Rachel Ginsberg, Mrs. Shoshana Friedman, Mrs. Rachel Bachrach, and my wife Tovah), we have been able to bring the topic of mental illness into the spotlight and to facilitate many important discussions about diagnosis and treatment for the sake of helping Am Yisrael. But perhaps most importantly, we have been able to decrease the stigma surrounding mental illness in the frum community and to provide hope to many individuals and their loved ones. For me, nothing could be more important.

Over the next two months, I’ll be taking a break to work on some new projects, with a plan to return to my weekly column in the summer. In the meantime, look out for questions and answers in the magazine’s new Talkbacks section, and please be in contact if I can ever be of help.

Chag kasher vesameach, and stay grateful, positive, and healthy!

Yaakov Freedman

Originally featured in Mispacha, Issue 757. Jacob L. Freedman is a psychiatrist and business consultant based in Israel. He can be reached most easily through his website www.drjacoblfreedman.com