Usually, when people first come to see me, they are in a state of desperation, fed up with the bald spots or sores that they have spent months or years trying to cover up and hating their hair-pulling or skin-picking behaviors with a passion.

On my intake forms, when I ask what people would like to get from our work together, the most frequent response is to get rid of their behaviors. I understand that response!

Goal-setting in therapy is a collaborative process, and my first task is to validate the urgent need to get rid of body-focused behaviors. After all, they have caused deep shame and despair, do immeasurable harm to the skin and hair, and seem so counter-productive. I make fiddle toys of various types and textures available in my office, offering a behavioral alternative from the start of treatment.

However, if urges stay high, a fiddle toy is no match for the relief and escape picking or pulling can bring. If we set a goal of elimination of the behavior, we may be setting ourselves up for failure. If success is measured by pull or pick free streaks no matter how strong the urge, a slip or relapse is likely. Relapses can be devastating and tend to lead to picking or pulling binges. If the goal is perfection, a slip becomes a failure.

On the other hand, if we can view success in more moderate terms, like reducing the urges to pick and pull and building more skills to deal with stressful situations and painful emotions, we can expect to bring the behavior to a moderate level. If we understand that in times of great stress or loss, we are likely to reach for our most reliable coping skills, we can be compassionate with ourselves when picking or pulling is impossible to resist.

Eventually, my clients and I come to agreement on these attainable goals. We examine how picking or pulling has helped them to regulate their nervous systems and manage difficult emotions like anger and sorrow. Body-focused repetitive behaviors are so compelling because they actually do provide comfort in the short term.

Without the pressure of immediate behavioral change, we can set an intermediate goal of learning to integrate new, adaptive emotional regulation skills. These include: becoming more aware of our feelings, learning to tolerate the wide range of emotions, being compassionate with ourselves, expressing feelings in productive ways, asserting our needs in relationships, and modulating our emotions so that we have a choice of how to respond to stimulating experiences rather than act impulsively.

My clients are relieved to find that as these skills become more accessible, they need to rely less and less on the behaviors that brought them to treatment. A hair pulled or scab picked doesn’t need to lead to a binge; rather, it can lead to awareness of a feeling or a need that can be met in some other way.

Paradoxically, setting the goal of moderation often takes us much farther than aiming to get rid of unwanted behaviors once and for all. In the process, we learn to set aside the idea of perfection and embrace the idea of good enough.