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 Much like the horses that are bored because the activity of grazing has been replaced by eating from a grain bucket, humans lack a lot of the stimulation our ancestors experienced in the process of taking care of the needs of daily life.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.

References:

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.