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.