become a conditioned stimulus for pulling. Thus, bedtime becomes a “high-risk” situation, or potential trigger for the pulling behavior. In certain contexts, the urge to pull never arose; there- fore, those specific contexts did not become potential triggers. One good example, to illustrate, would be the context of socializing with friends. The urge to pull did not surface in this context, likely because Teri was more engaged (i.e., not bored) with friends, and/or because of the embar- rassment that would have been associated with pulling publicly. In essence, classical condition- ing explains why the urge to pull was triggered by some environmental contexts, but not others. Using an operant conditioning lens, Teri’s behavior resulted from a longstanding history of negative and positive reinforcement . Negative reinforcement occurs when a target behavior (i.e., hair-pulling) is followed by the removal of something unpleasant (thus strengthening that behav- ior); positive reinforcement occurs when a target behavior results in a pleasurable consequence (thus also strengthening the behavior). Although initially triggered by boredom, anxiety, or fas- cination with unusual hairs, Teri’s episodes quickly escalated to a point of overwhelming urges and impulses. These urges would become quite strong, felt nearly impossible to refuse, and were associated with significant tension and anxiety. Once hair-pulling began, this sense of tension abated quickly and significantly, thus negatively reinforcing her pulling behavior. Moreover, she described feeling a pleasurable relief akin to a “high” after pulling, a desirable feeling that served to positively reinforce her behavior. This combined influence of dissipating tension and immense pleasure/relief, especially over the course of many years, undoubtedly served to strengthen Teri’s hair-pulling over time. As outlined, behavioral processes have clearly played a role in the development of Teri’s hair- pulling. Thus, the Keuthen et al. (2001) emphasis on behavioral strategies for TTM makes for a good fit with this conceptualization. Drawing from the perspective of classical conditioning, HRT was chosen as a strategy; as described earlier, HRT involves not only awareness training, but also identification of CRs for use in situations involving the problem behavior. In an operant sense, also as recommended by Keuthen et al. (2001), it was decided that implementing a punish- ment contingency could be useful to counter the reinforcing effects of pulling. The behavioral factors noted above are important in understanding Teri’s pulling. Nevertheless, those factors do not address the potential cognitive elements of the problem, as would be sug- gested by a CBT framework. Indeed, Teri openly addressed how she would sometimes “obsess” over whether or not to pull during her urges. More specifically, she described ambivalence during these episodes, simultaneously weighing the value of pulling (to obtain relief) with the value of refraining from pulling (to maintain her appearance). This insight from Teri suggested that her thought processes likely played an important role in her pulling. It is possible that Teri was enter-
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