Why Resistance Is a Normal Part of BFRB Treatment

You know the story. You hate your body-focused repetitive behavior, and all you want in the world is to get rid of it. You tell yourself to stop picking or pulling, and you are frustrated that at the same time, your hand is reaching up to your hair or skin.

Maybe you’ve delayed seeking therapy, with a nagging part of you saying you'll start next week, or next month. You might have recently started treatment, but you’re frustrated the therapist doesn't have a magic want to keep your hands from doing damage to your hair or skin.

Therapy might even make this inner conflict more difficult—you're more aware of the triggers for your behaviors, you've committed to learning new ways of coping with stress, and you can no longer push away the pain the behavior brings to your life. And yet here you are, still picking or pulling!

This inner conflict is okay. It means you have bumped into your own resistance to change. You are not alone in this—everyone struggles to let go of behaviors they know are harmful to them! Think of all of the times people try to quit smoking or resolve on January 1st to hit the gym, then find themselves buying a pack of cigarettes or wasting money on that unused fitness membership.

Because resistance to change is universal, it can be helpful to understand why we cling to the very behaviors that harm us the most. To begin with, it’s important to understand that problematic behaviors have an important role in our lives, so much so that the idea of letting go of them brings up feelings of anxiety that can’t be ignored.

Picking and pulling serve many different functions. The behaviors can help us wind down after a hard day, relieve stress and tension, enable us to escape emotional discomfort, help us cope with feelings that are hard to sit with, boost our focus and concentration on a difficult problem, or keep our hands busy when we’re bored at work, school, or in the car. It may sound strange, but BFRBs can also serve as friends—always available to occupy our time and relieve stress. And, of course, your hair and skin are right there, you don’t even need to head out the door to find your old trusty way to comfort your central nervous system when life gets stressful! If we think about getting rid of one of our friends who comforts us, we can see why letting go is easier said than done!

One way I address this resistance is to shift the focus away from getting rid of a behavior. That way, we can sidestep the tug-of-war between the parts of ourselves that want to let go and the parts that want to cling to the way things are. Instead, I focus on what needs the behavior meets.

For example, a pre-teen client of mine, who hated using the fiddle toys her parents often encouraged her to pick up, recently side-stepped her resistance to change. During a test, she found herself pulling out a hair. Instead of thinking, “Stop it!” she took my suggestion to instead ask herself, “What does my body need right now?” She realized that she was feeling frustrated and trapped in her seat, and asked the teacher if she could take a stretch break. She came back to her desk and finished her test, and her hand didn’t go back up to her hair!

In this way, if we think about bringing in new behaviors to meet our needs—whether for physical or emotional comfort, relief of tension, or help focusing—we may be able to add to our emotional regulation toolbox without kicking out body-focused behaviors. Without the pressure to get rid of our trusty old behaviors, we may have more capacity to reach for other tools.

How to Use a Whiteboard for Therapy Breakthroughs

Several years ago, a client brought a whiteboard into a session and used it to map out confusing thoughts in his mind. Now I have my own whiteboard, and find it very helpful when a client is stuck in some way and we need a tool to change thought processes and behaviors. The open, erasable canvas of the whiteboard allows me and my clients to get creative as we decide how to use the whiteboard in the moment—we can include pictures as well as words, adding connections as we go along.

The whiteboard can be used to shake off ingrained patterns of behavior. My whiteboard has enabled conversations with clients about how they might be able to build up emotional insulation, so that every outward critique doesn't have to lead to a boomerang cycle of hate and self-attack.

On the board, I might put the client's name in a circle. Then I draw a wide, shaded area around the circle, a buffer zone between the self and the world. We talk about the importance of noticing when emotional "arrows" come our way, and how we can pause, reflect, and restrain impulses before acting in the moment. Exploring a few questions can help create new options for possible response: What happened? How did I feel? What does it mean? (Here it's a good idea to name a few different possibilities—including the worst fear but also more positive scenarios.) And finally: What do I want to do about it? We can use the board to work through examples.

A board can also be used to trace a journey from a hated behavior back to its roots, making room for compassion along the way as we discover how the behavior helped the client cope with difficult circumstances.

Mind-mapping, writing a word on the board, and drawing lines to associations that arise—all of these can help our clients move past defenses to connect thoughts, feelings and behaviors.

Some of my favorite work on the whiteboard happens when drawing images that come to mind during sessions. Recently, I imagined with a teen client an undernourished sapling next to a "poison tree" being watered by negative self-talk, helping her understand the consequences of continuing to invest in her self-hatred.

The best part of using a whiteboard in therapy sessions? Endless possibilities!

Family Therapy for Adolescents with Body-Focused Repetitive Behaviors

With my pre-teen and teen clients, I often find that family therapy can play an important part of our work together. Family members can provide needed support for the person struggling with an unwanted behavior, often by making changes and adjustments in the family environment. Family systems theory holds that problem behaviors in adolescents are related to dynamics within the family as a whole (Bowen, 1978).

People who struggle with body-focused repetitive behaviors (BFRBs) tend to have highly sensitive nervous systems, and often pick up on unspoken tensions in the family unit. While it can be a relief to think that therapists can “fix” an individual, it’s more realistic to assess the individual in the context of the family and seek opportunities to address and resolve underlying tensions within the family unit. This can help reduce the level of stress that’s accumulated in the “stress cup” of the person who is picking or pulling (see blog from May 2017).

Tracing the behavioral symptoms of an adolescent to family dynamics doesn’t mean that parents are to blame for the symptoms. Rather, it means the sensitive child is bringing a gift of awareness to feelings and experiences that are understandably difficult for families to navigate. Family therapy can help parents to feel empowered to make a difference, even though they have no control over what their teen or pre-teen does to their skin or hair. Bringing unspoken concerns out into the open can “unbottle” long-contained feelings and relieve some of the stress surrounding those concerns. This unspoken stress may play a part in what motivates a teen or pre-teen to pick or pull.

Nancy Keuthen et al (2013), experts in BFRB research, studied the families of approximately 50 adolescents who struggled with trichotillomania. The study also focused on mothers, with the goal of determining whether dynamics in the families were similar. The results were intriguing. Researchers found that the mothers in the study exhibited greater frequency of depression, anxiety, and anger than a control group, and both the adolescents and their mothers reported greater family conflict and less overall family support. Adolescents with trichotillomania reported feeling less freedom and independence than those in the control group. This study did not prove a causal relationship between these factors and the development of trichotillomania, but did present intriguing connections that warrant further study.

In my work, I’ve noticed that adolescents in families who accept the challenge of participating in family therapy tend to experience greater healing. Parents often bring to my attention issues that may have contributed to the development of their child’s BFRB, such as geographic relocations, divorce, or loss of a loved one. Many parents haven’t received any help or support experiencing and moving through their own reactions to these experiences, and though they do their best, they aren’t able to help their children grieve or process their emotions, instead encouraging the whole family to move on. Also, when a child develops a BFRB the behavior has an effect on all members of the family system, and these new stressors need to be acknowledged and discussed.

In family sessions, I can help all members of the family learn how to grieve these losses together, which produces a powerful bonding experience. In other cases, parents who want to protect their children from the painful and dangerous minefields of adolescents may learn through family therapy how to negotiate more flexible boundaries as their teenager works to earn their trust. In addition, family therapy can be helpful in working through some of the stresses the BFRB causes for other members of the family, including self-blame and feelings of overwhelm.

Two families I’ve worked with agreed to participate in six-month follow up interviews (conducted by a graduate student) to assess the effectiveness of our work together, with a focus on how family therapy fit into their healing process. Both teen clients chose pseudonyms for themselves—Colt and Nikki.


Colt and I met regularly for two years. His parents came to the first half of each session and left for the second half. Initially, spending time with his family in the room helped Colt to relax and build trust in me. We found that the split sessions also helped his parents bring up issues or conflicts that Colt might not have mentioned on his own. Then he and I could work on those concerns during the rest of our time together. Six months post-treatment, he and his parents agreed that he had resolved his hair-pulling behavior. This is what each of them said about what worked in their therapy:

Colt: [Stacy] taught me how to deal with the nervous stuff. When I was coming here, (my hair-pulling) was out of control. But then when I left, I was totally controlled.

Colt’s Mom: I think Stacy really took into account all three of us and how we all worked together. I think she took us into consideration when she was helping Colt.

Colt’s Dad: I think the relationship (with Stacy) evolved. When we first came, it was all about Colt, and then it became about this family working really hard. She joined in that fight with us. We really gelled well.

Nikki, who saw me individually for three years for trichotillomania with family therapy included as needed, decreased her hair-pulling to a level that no longer distressed her. She came in alone for her post-treatment interview, and explained the importance of family sessions in our work together: “I was talking to Stacy about something and she was just like, why don’t we bring your mom in? My mom came in for a bit, and it was super helpful. I hadn’t been telling her things, and she hadn’t been telling me things. And then it was a lot easier once we were communicating. I told her that when she wanted me to put Band Aids on all the time, she made me feel bad. I was judgmental toward myself, and once she told me it was okay, it just helped a lot.”

Of course, it is natural for families to feel anxious and reluctant about giving family therapy a try. It may feel like it is just the problem of the person with the BFRBs, and it is always scary to do something new and unknown. Many of my clients find that the power of working as a family team to conquer a problem along with the relief that can come from that work is worth facing those fears.


Bowen, M. (1978). Family therapy in clinical practice. Lanham, MD: Rowman & Littlefield.

Keuthen, N., Fama, Jl, Attenburger, E, Allan, A., Raff, A., & Pauls, D. (2013). Family environment in adolescent trichotillomania. Journal of Obsessive-Compulsive and Related Disorders (Volume 2, Issue 4), 366-274.

Internalized Anger as a Trigger for Picking and Pulling

Soon after my clients begin treatment for picking and/or pulling, I tend to bring up the topic of anger. This is not a topic most of my clients are comfortable discussing. 

Over the years, I’ve noticed that many pickers and pullers bottle up their anger rather than expressing it, and that this internalized anger often becomes a trigger for their body-focused repetitive behaviors (BFRBs). Suppressing anger can be a useful coping mechanism, as parents and others may react negatively to its expression, and reversing this ingrained response often feels like a dangerous and overwhelming proposition.

In 2016, Curley, Tung & Keuthen published a study titled “Trait Anger, Anger Expression, and Anger Control in Trichotillomania: Evidence for the Emotion Regulation Model.” The study focuses on the connection between the internalization of anger and BFRBs. 

Their conclusions validate my focus on helping my clients to express their anger. "This study demonstrates that there is a clear relationship between TTM [trichotillomania] and anger directed inward. Individuals with TTM have both a tendency to suppress anger and difficulty controlling and reducing this inward expression of anger, suggesting that hair pullers may have trouble regulating their anger" (p. 79).

One way I can help my clients reduce the stress in their "stress cups," (see May's blog below) and take pressure off the need to pick or pull is to help them regulate their anger effectively instead of turning it inward. This process involves several steps:

1.    Identify angry feelings and locate them in the body.
Many who struggle with BFRBs have turned off internal emotional sensors, especially those related to anger, in order to cope with their environments. When I am with a client, I often notice cues that they are angry or irritated, either with me or with someone else. These cues might include using a curse word or slapping a knee while talking. In these moments, I can help them check in with their bodies to see if there might be some tightness or other sensation somewhere inside. I can help to name this sensation as anger and take some of its power away. As we go along, we can begin connect what we were talking about in our session with that uneasy feeling.

2.    Understand how suppressing feelings has worked as a coping mechanism.

Anger can feel very scary. Many people have valid fears about what might happen if they turn their aggressive impulses toward others. We can begin to understand the ways anger at others is turned toward the self through negative self-talk and engagment in BFRBs. Once the reliance on self-defeating behaviors is understood, it is easier to consider that an outward expression of anger might be safe in a new, healthier environment. 

3.    Develop emotional regulation skills. 

I encourage clients to express their anger or frustration at me when it arises. By encouraging the expression of anger in the moment, I can help them them to begin to calm themselves down. Neurobiological research explains how a therapist's calm and centered presence can help clients begin to relax their central nervous systems.  My response to a client's dissatisfaction with me is to validate and invite negative feedback. I explain that their expression of anger helps me to get to know them and can help me understand how to be a better therapist. In order to help them to bring these regulation strategies into their daily lives, I often share the metaphor of an anger pendulum. I explain that if we’ve been repressing anger, we may be clumsy when we try to express it, sometimes blowing up or saying hurtful things, moving from passive to aggressive. Luckily, as we get more comfortable with our angry feelings, we can begin to communicate them more effectively and move into the middle ground between passivity and aggression,  assertiveness. Additionally, I often encourage physical activity as an emotional release.

It takes courage to get in touch with feelings that have we have repressed like grief and anger. The good news is that our bodies have all of the information we need to cue in to these unwanted feelings and begin to befriend them. A therapist's presence can make it easier to relax while discussing painful feelings and begin to soften the pain we have been trying to avoid. Once we are comfortable with expressing our anger in healthy, productive ways, we may notice less pressure on the stress cup that contributes to engagement in picking and pulling. 


Curley, E., Tung, E. & Keuthen, N. (2016). Trait anger, anger expression, and anger control in trichotillomania: Evidence for the emotion regulation model. Journal of Obsessive-Compulsive and Related Disorders, 9, 77-81. 

A Key Metaphor in My Work with BFRBs: The Stress Cup

Many of my clients enter therapy hating the fact that they pick and/or pull. They have usually been struggling with the unwanted behavior for months or years, and the resulting sores, bald spots, and shame can be excruciating. As a result, people often want me to help them to get rid of these behaviors immediately.

Many therapists do start treatment with a behavioral plan, with or without habit reversal therapy, addressing the symptom directly and working toward symptom reduction. Some behavioral techniques can be helpful at the start of treatment, especially finding fiddle toys that feel good to play with to help meet the sensory needs that underlie many BFRBs. However, I have found that trying to stop behaviors without exploring their causes and effects can lead to short-lived success at best.

To explain this dilemma to my clients, I like to use a metaphor. I ask them to visualize an imaginary cup, somewhere inside of the body, collecting stress that comes its way. Sometimes, when the cup is full stress, urges to pick or pull will be high and frequent. If we try to reduce our coping behaviors while the cup is full, we won't have much of a chance. If instead we work on relieving some of the stresses that fill up our internal cups, urges to pick or pull may become more manageable.

For example, let's say Jon is an eleven year old boy who comes to see me for pulling out his hair. One day, he opens our session by telling me how angry he is at himself for pulling out hair from a spot where he has been working really hard to let the hair grow back. After bringing some compassion into the mix re: how hard it is when so much work is lost in the space of a few minutes and how hard it is to resist when pulling urges are high, we can explore what physical and emotional stressors were filling up his cup. In the session, I can help Jon to calm himself down, as well as to express his hurt feelings from an incident at home or school. This emotional regulation strategy is enabled by our positive relationship, as I help him to build up his ability to calm himself down without turning to a self-attack.

The stress cup metaphor can open up new treatment landscapes. Instead of focusing on the despised behavior and trying to fight urges to pick and pull, together we can explore the physiological, emotional and situational stressors that fill my clients' cups. With this focus, we can develop a trusting relationship as we work to understand the ways picking or pulling has been useful in coping with the stresses in their lives. At the same time, I can assist in the development of self-compassion, one key to lasting change.

Defining Body-Focused Repetitive Behaviors (BFRBs)

Body-focused repetitive behaviors are difficult to define. trichotillomania (hair-pulling) was only included in the Diagnostic and Statistical Manual (DSM) in 1987, while excoriation "skin-picking" disorder was only added in the fifth edition in 2013. Hair-pulling moved from the umbrella category "impulse control disorder" to that of "obsessive-compulsive and related disorders" in the same edition. These behaviors are hard to categorize because they are not well researched and understood, they manifest hand in hand with a variety of other diagnoses, and they have both impulsive and compulsive features.

In animals, similar behaviors such as feather plucking and excessive licking are called "over-grooming behaviors," and are linked to stressful circumstances including being isolated, bored, cramped in a small space and frustrated. In humans, these same circumstances tend to be triggers, and "over-grooming behaviors" is one simple way to define BFRBs.

In the DSM 5, hair-pulling and skin-picking are defined in separate diagnoses as, roughly: recurrent pulling out or picking of one's hair and skin, with repeated effort to decrease or stop the behaviors, resulting in significant distress, when the symptoms are not caused by a medical condition or another mental disorder. 

Researchers are advocating for the inclusion of a new umbrella category into the next version of the DSM. The category would be body-focused repetitive behaviors and would include hair-pulling, skin picking, as well as clinical levels of nail-biting and nose-picking (Stein et al., 2010). 

In an article reviewing the literature on the subject, Roberts, O'Connor & Belanger (2013) define BFRBs as “a group of problematic, destructive, and apparently non-functional behaviors directed toward the body, including hair-pulling (trichotillomania, TTM) skin-picking, and nail-biting...BFRBs are recurrent, undesired, and often designed to remove part of the body…individuals with BFRBs report diminished control over the behavior…and a range of physical and psychological sequelae."

From my perspective as a psychodynamic therapist,  these definitions leave out a couple of important elements. Specifically, I have learned that BFRBS do in fact have a function, as coping mechanisms, to soothe particularly sensitive nervous systems and to regulate emotions.

Adding these components, my definition of BFRBs is as follows: BFRBs are repetitive, over-grooming behaviors involving damage to the dermis (hair, skin or nails) that emerge as coping mechanisms (hard comforts, action symptoms) in people with particularly sensitive nervous systems, under a variety of stressors, the main function of which is to regulate emotions, bringing a short-lived sense of relief or escape that is usually followed by shame and frustration and can negatively impact many areas of life. 


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.

Roberts, S., O’Connor, K & Belanger, C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology review, 33, (pp. 745-762).

Stein, D., Grant, Jon, Franklin, M., Keuthen, N., Lochner, C., Singer, H., & Woods, D. (2010). Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: toward DSM-V. Depression and Anxiety, 27, (pp. 611-626.)

The Voice Winter 2017

Please copy and paste this link to The Voice, the Austin Group Psychotherapy Society's newsletter, edited by myself and Gianna Viola.


Alejandra Spector's essay on race in America, "Home of the Brave" is especially timely and thought-provoking. 


I'm Back!

I have neglected my blog for the past few months, but I am ready to check back in. Don't worry, I've still been writing! In February, I will be posting a piece about my psychodynamic formulation of the definition of Body-Focused Repetitive Behaviors. In the meantime, stay tuned for a link to the Winter edition of The Voice! 

Another Sneak Peek of My Book: "A Tri-Phasic, Integrative Approach to Treatment for Hair-Pulling and Skin-Picking"

From Chapter 6: Interventions:  Broadening the Therapeutic Toolbox

Develop Mindfulness and Self-Compassion

Gerner and Neff (2015) explore how the pursuit of mindfulness and self-compassion guide our next interventions: “Mindfulness primarily invites the question ‘What are you experiencing?’ and self-compassion asks, ‘What do you at need?’” (p. 48).

Meet Underlying Needs

Find Sensory Replacement Behaviors

Our clients will most likely come to us with unmet sensory needs, which can include both being over-stimulated, indicating the need for soothing, and under-stimulated, indicating a need for more sensory input. I introduce fiddle toys into my work early on. Sensory issues can be met to some extent with tactile, visual, and/or oral "fiddle toys", a behavioral intervention.

When clients find a fiddle toy in my office that suits their sensory needs, I usually mention some local stores that carry that fiddle toy. In some cases, especially with pre-teens, I give clients a fiddle toy to take home with them. Then, the toy serves as a kind of transitional object, helping my client to internalize the soothing experience she had with me. As Maya once explained in a session, I was her best friend, and the stress ball w/hair and eyes I had given her was also her best friend, and she kept it in her purse every day and touched it when she needed comfort.

Some of these sensory interventions can mitigate a one dimension of boredom—under-stimulation of the hands. Boredom is a common experience in today’s technological world. Much like the horses that are bored because the activity of grazing has been replaced by eating from a grain bucket, humans lack a lot of the stimulation our ancestors experienced in the process of taking care of the needs of daily life. For horses who have been pacing or cribbing (taking in huge gulps of air), one way to alleviate boredom is to take them out to pasture to graze. Similarly, many of my clients with BFRBs have benefitted from slowing down some of their daily tasks: cooking rather than eating out, hand-crafting rather than buying jewelry, writing letters rather than texting.

Increase Coping Skills

 Work with our clients on coping skills arises within the relationships and circumstances of our clients’ lives. Often, my clients come up with particularly well-suited behavioral strategies organically. For example, one day Stephanie forgot about our session, and was too busy with her children to drive over when I called, so we had a phone session. She mentioned that although her picking has been better over the past couple of months, in the past couple of days she has been picking a lot. She talked through the stress of juggling a new job and her children’s summer vacation. I asked if she has found any ways to release stress besides picking at her skin and talking to me. She mentioned that right then, as we were talking on the phone, she was giving herself a manicure, finding it soothing. I noted that she had discovered a healthy grooming replacement behavior on her own. As we kept talking, she mentioned that she also has been keeping a ‘messy journal’ in addition to her usual diary. She described her documentation of painful feelings and experiences in this journal, scribbling and crossing things out, thus escaping from the perfectionism that usually guides her writing. In the session, she began to realize that she had her own ideas for behavioral interventions. I was amazed to find that all she needed from me was recognition and validation of her movement toward self-care.

Increase Emotional Expression and Regulation

 Increasingly, experts are prioritizing improvement of emotional regulation (ER) as key to letting go of reliance on BFRBs (Roberts, O’Connor and Belanger, 2013). Studies have shown that pickers and pullers have significantly higher levels of emotional stress than control groups and that BFRBs serve as short-term strategies to decrease feelings of boredom, sadness, anger and tension. Curley, Tung & Keuthen (2016) explain, “Researchers have invoked emotion regulation (ER) as one explanatory model for [trichotillomania]. This model posits that individuals with TTM may have difficulty managing certain negative emotions and engage in hair pulling behaviors as a coping mechanism, thus relieving the negative affective state and reinforcing the hair pulling behavior (p. 77). Frustration and anger are frequently cited as triggers, and recent study found a correlation between the internalization of anger and engagement in BFRBs (Curley, Tung & Keuthen, 2016).

An important step toward emotional regulation is emotional expression, because, as adults, we need to be able to give voice to uncomfortable feelings in order to truly soothe ourselves. Sadness and anger are important emotions to accept and express with compassion, and Greenberg & Pavio (1997) explain that the crucial role of the therapist in helping clients to sit with these feelings rather than trying to squelch them. “Solutions to the problems of pain and sadness come by allowing and accepting the pain, and experiencing and expressing it, in order to live through it and come out the other end” (p. 167).

Given that the internalized anger and frustration are common components of BFRB development and maintenance, communication about feelings, especially anger and frustration, is key to work with this population. Engaging in BFRBs can be akin to swallowing uncomfortable feelings and letting them out bit by bit. Anger expression leads to a natural action tendency of setting boundaries, and I encourage its expression, at me and at others. When a person is aware of being angry and can express her feelings, she can also be clear about and express her needs, a key to assertiveness. Similarly, I encourage the expression of sadness whenever it arises in sessions.


Curley, E., Tung, E. & Keuthen, N. (2016). Trait anger, anger expression and anger control in trichotillomania: Evidence for the emotion regulation model. Journal of Obsessive-Compulsive and Related Disorders, (2) 77-81.

Gerner, C. and Neff, K. (2015). Cultivating self-compassion in trauma survivors. In V. Colette, J. Briere, D. Roselle, J. Hopper, D. Rome, V. Follett (eds.), Mindfulness-oriented interventions for trauma: Integrating contemplative practices (pp. 43-58). New York, NY: Guilford Press.

Greenberg, L. & Paivio, S. (2007). Working with emotions in psychotherapy. New York, New York: The Guilford Press.

Roberts, S., O’Connor, K, & Belanger C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33, 745-762.

Sneak Peek of My Upcoming Book, "A Tri-Phasic, Integrative Approach to Treatment for Hair-Pulling and Skin-Picking"

From Chapter 3: Multi-layered assessment: Assessing symptoms, stressors and resiliency factors

Typically, cognitive-behavioral therapists working with clients struggling with BFRBs assess primarily for symptom severity and type (automatic, focused or a combination of the two) and for co-morbid conditions such as depression or anxiety. In ComB, the enhanced cognitive-behavioral treatment recommended for this population (Trichotillomania Learning Center, 2011), the assessment process stops there. In a review of treatments that address the emotional regulation components of BFRBs, Roberts, O’Connor & Belanger (2013) explain, “the (ComB) model does not attempt to explain why an individual begins to pull hair, pick skin, or bite nails,” (p. 749).

In contrast, I am interested in understanding the full pictures of my clients’ lives, from sensory processing issues to relationships, from trauma to successes. I conduct an on-going and multilayered assessment process with each person who walks into my office. I think of BFRBs as guides to the inner map of each person’s life experience. Following this map allows me to help clients to process emotions, needs, and losses that arise along the way.  Thus, assessment of symptom frequency, severity and type and co-morbid conditions is only the first part of my assessment process.

Throughout treatment, I continue my assessment of symptoms on a deeper, ongoing level, seeking to understand how and when symptoms developed for each client as well as times when they have lessened or worsened and how these changes may relate to everyday triggers. This process helps me to understand the specific stressors and sensory and emotional needs of each client.

My assessment of each client covers at least eleven items: (1) symptom severity and consequences (2) symptom frequency (3) symptom type (4) co-morbidity (5) self-compassion (6) sensory processing issues (7) precipitating event (8) environmental stressors (9) attachment style (10) trauma history (11) resiliency factors.

In the full chapter, I explicate each of these categories, exploring how the assessment process with four clients informs the creation of their individualized treatment plans.


Roberts, S., O’Connor, K, & Belanger C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33, 745-762.

Art Therapy for BFRBs: Translating the Body's Metaphors

Similar to dreams, art can help our clients to symbolize emotions and experiences they may not be able to express in words, giving the clinician greater access to the client’s unconscious (Holmes, 2001).  Not all of our clients will benefit from art therapy, but for those who have a natural relationship with art, images can provide an opportunity to explore body-focused repetitive behaviors (BFRBs) more deeply.  Art can help to uncover memories and meanings that reside just outside conscious awareness and can trigger impulsive/compulseive behaviors like BFRBs. Through art, we can help our clients to reflect on their own experience and put their feelings into words, important building blocks toward an creating an earned secure therapeutic attachment.

Michelle M. has collaborated with me on this blog post. We both wanted to honor the way art therapy helped us to move through a therapeutic impasse. In a session three years into the five years we worked together, Michelle struggled to explain to me how she first discovered the power of attacking her body to calm herself.  She was angry and frustrated with me at the end of the session, mad that she still wasn’t improving as a result of therapy. She told me angrily that she was was pulling “more than ever”.  She went home and drew a picture and shared it with me in our next session.

The piece (attached below) provided a clear picture of how important hair pulling was in her life, helping us both to understand why any of our gentle attempts to work on the behavior met with great resistance. Michelle was able to put into words for the first time how hair pulling had helped her survive a traumatic childhood filled with neglect and abuse.

  "I made this drawing during therapy attempting to describe the feelings I had at the  beginning of my pulling. I'm 12 years old in the drawing and remembering how good it felt to have something of my own for the first time. A tough period of my life during puberty and my parents divorce, I found solace in my exploration as I had with skin picking up to that time, I found a place to go." Michelle M.

"I made this drawing during therapy attempting to describe the feelings I had at the  beginning of my pulling. I'm 12 years old in the drawing and remembering how good it felt to have something of my own for the first time. A tough period of my life during puberty and my parents divorce, I found solace in my exploration as I had with skin picking up to that time, I found a place to go." Michelle M.

Another of Michelle's drawings captures her diffiicult-to-describe experience of dissociating during automatic pulling sessions. Here, she is floating in a space suit, with a single hair between her fingers.

More recently, Michelle has utilized her art to find acceptance for herself as a hair-puller.  This self-acceptance has led her to re-enter therapy to work more on the hair-pulling behavior itself. The piece below reflects the sad beauty of her journey.


Michelle's case illustrates an important component of my work, one that distinguishes it from cognitive behavioral therapy (CBT). The symptom-relief focus of CBT can be traumatic for those whose relationships with their BFRBs run deep. My psychodynamic approach includes a phase of safety-building before exploration of any symptoms, as recommended in the evidence-based approach of Courtois and Ford (2013). The primary goal of my work with Michelle was not to alleviate her hair-pulling symptom. Instead, my first goal with her was to build a stable enough foundation for her to begin to thrive. In our work together, Michelle internalized a more secure attachment structure, which in turn enabled her to live a more organized and satisfying life. Often, symptom relief comes when other resources are improved. Michelle's story exemplifies the fact that successful treatment does not depend on this outcome.


Courtois, C. & Ford, J. (2013). Treatment of complex trauma: A sequenced, relationship-based approach. NY, NY: The Guildford Press.

Holmes, J. (2001). The search for the secure base: Attachment Theory and Psychotherapy. Philadelphia, PA: Taylor and Francis, Inc.

The Voice-Spring 2016

I will be blogging about Art Therapy in BFRB treatment in April.

I've been busy this month in my new role as co-editor of The Voice (along with Gianna Viola, LCSW), the newsletter of the Austin Group Psychotherapy Society.  

Just copy and paste the url below to see the Spring issue. Enjoy!





Group Therapy for BFRBs

One way to conceptualize BFRBs is as overgrooming behaviors, or “grooming gone wild.” In a chapter of that name, Natterson-Horowitz and Browers (2013) discuss the research into similarly body-focused repetitive behaviors such as over-licking, barbering and feather-plucking among domesticated or captive animals. A common finding across species is that these behaviors are triggered by isolation, frustration, boredom and the stress of being trapped in too small of a space (Natterson-Horowitz & Browers, 2013). Encouragingly, research also shows that improvement of the conditions of an over-grooming animal’s environment can lead to a reduction or elimination of the behaviors.

In fact, the benefits of addressing the isolation of an over-grooming animal by providing more social contact can be profound. Incredibly, benefits of this contact can be seen across species. Natterson-Horowitz and Browers (2013) describe a case in which a horse’s flank-biting behavior declined when a chicken was added to his pen, as his triggering experience of isolation decreased.

For similar reasons, group therapy is an evidence-based modality for treatment of many behaviors and diagnoses (Blackmore, et al., 2009). As with animals, common triggers for engagement in BFRBs in humans include boredom, anxiety, frustration and tension (Roberts, O’Connor & Belanger, 2013). Group therapy is uniquely suited to address these issues.

Group therapy can provide access to a ‘healing herd’ for people who struggle with picking and pullng behaviors. Group therapy directly addresses the isolation that is often both a precipitant and consequence of reliance on BFRBs. My groups provide a supportive environment in which members can share some of the details of their engagement in BFRBs. This sharing allows them to develop self-compassion, an important ingredient in the healing process. Brene Brown (2012) explains,  “Self-compassion is key because when we’re able to be gentle with ourselves in the midst of shame, we’re more likely to reach out, connect, and experience empathy.” Self-compassion is the best antidote to the BFRB engagement/shame/intensified BFRB engagement cycle that frequently multiplies stress for pickers and pullers.

One goal of psychodynamic group therapy is for members to talk about the feelings that underlie problematic behaviors. With many clients, and with pickers and pullers in particular, frustration and anger are some of the feelings that are most likely to have been suppressed. The expression of some of those ‘bad’ feelings to supportive group members can be transformative.

I have led a number of groups for pre-teens and teens who pick and pull. This modality can be more effective than individual therapy at helping adolescents shake off the shame that has coated their secret engagement in BFRBs. In my experience, this relief, along with the opportunity to vent frustrations and connect with peers, usually leads to a reduction in BFRB symptoms.

I run three weekly general process groups for adults, many of whom are pickers and pullers. This week, in one of my adult groups, I was reminded of how perfect this modality for helping my clients put their behavioral symptoms into words. P has been with me in group and individual therapy with me for several years. Through the years, I have watched P gain confidence, form healthier relationships, and re-engage in art. Still, she struggles with recognizing some of her unpleasant feelings and putting them into words. Over the years, I have gotten to know P’s ‘go-to’ non-verbal communication when she is distressed—she presses on her thumb, soothing herself while withdrawing from the group.

At times, I have tried to comment directly on this behavior, to no effect. P has always given me the clear message that she doesn’t want to talk about it. In this week’s group, I noticed that whenever P was talking, she wasn’t pressing on her finger. The longer she went without giving her input into a conversation, the more she would engage in the behavior. I engaged the group in a question about what they leave out of the room in their ‘niceness,’ and by the end of the group P. was talking more and thumb-pressing less.

In our individual session later in the week, I mentioned that I want to write about what I noticed about her behavior in group, and asked her permission to include this vignette in my blog.  She agreed. She was interested in my observations, and told me that she hadn’t noticed that she had been using her “thumb soothing” technique this week. She did, however, remember pressing sharply on her thumb a lot during last week’s group.  She told me she has been having trouble expressing her irritation at another group member, and had “hated” group that week. We agreed to continue working in bringing her angry feelings into the group room in words.

Animal behaviorist Robin Dunbar (1996) hypothesizes that when primates evolved into humans, the development of language replaced grooming behaviors in many of their social functions: communication, peace-making, and the establishment of hierarchy. 

In my experience, the power of group therapy when applied to over-grooming behaviors lends credence to Dunbar’s hypothesis. Unconsciously, BFRBs can serve as communications of unexpressed needs and feelings as well as unspoken social and familial dynamics. In P’s case, verbal expression is beginning to replace body-focused behaviors, as her ability to put words to her thoughts and feelings grows through her participation in the group.


Blackmore, C., Beecroft C., Parry, G., Booth, A., Tantam, D., Chambers, E., ... Saxon, D. (2009). A systematic review of the efficacy and clinical effectiveness of group analysis and analytic/psychodynamic group psychotherapy. Sheffield, UK: University of Sheffield.

Brown, Brene. (2012). Daring greatly: How the courage to be vulnerable transforms the way we live, love, parent, and lead. NY, NY: Penguin Group.

Dunbar, R. (1996). Grooming, gossip and the development of language. London: Faber & Faber.

Natterson-Horowitz, B., & Bowers, K. (2013). Zoobiquity: The astonishing connection between human and animal health. New York, NY: Vintage.

Roberts, S., O’Connor, K, & Belanger, C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33 (pp. 745-762).





In honor of the new year and a new website, I want to make an intention to utilize this blog to share some thoughts about the work that I do at Lotus Therapy.  2015 was a big year, with the publication of my first peer-reviewed article in the International Journal of Group Psychotherapy. In addition, I implemented an assessment tool--the Massachusetts General Hospital Hair-Pulling Scale (MGH-HPS) (revised)--so that those clients who are interested in reducing body-focused behaviors can have a tangible measure of their progress in therapy. The 39th Street Wellness office is full and thriving. 

2016 is shaping up to be a big year!  After 3 years of writing ups and downs I have a plan to submit a book proposal to a variety of publishers later this year. The working title is: A Tri-Phasic, Integrative Approach to Treatment for Hair-Pulling and Skin-Picking.  I am working with a writing coach through Write By Night and highly recommend them for those of you who might benefit from support in your writing endeavors, personal or professional.

My goal is to write a monthly blog, exploring some of the themes of my book, including the benefits of a tri-phasic, trauma-informed approach to BFRB treatment and the specific benefits of group, family and art therapy in BFRB treatment.

Signing off until February!