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.