In the previous blog post, I discussed the connection between body-focused repetitive behaviors in humans and in domesticated animals. One example of a BFRB in horses is a behavior called cribbing, in which a horse takes in a noisy gulp of air, releasing endorphins and calming the central nervous system. In the case of cribbing, isolation is often a factor.

Fun fact: animal behaviorists have found that cribbing can be alleviated in a horse by adding other horses to its pen. In fact, even adding a member of a number of different species, like a duck, sheep, small donkey or dog, can provide the companionship a horse needs to let go of the behaviors.

When it comes to humans, and how isolation factors into BFRBs, it’s much more complicated. Picking and pulling often come into play in adolescence. Not only are hormones raging, but belonging is the key developmental task. Feeling left out can trigger picking and pulling and social anxiety is a common co-morbid condition. In addition, picking and pulling behaviors leave such visible marks they tend to lead people to camouflage and isolate even more. In this way, Isolation and BFRBs often become part of a vicious circle.

One important aspect of isolation in this population is that people who pick and pull often appear to fit in socially. They may be over-achievers who take on roles like class president or cheerleading captain, seeming like they have it all together. Often, they mask not only bald spots or scars, but also their feelings, putting on a happy front that keeps people knowing the real them. While it is painful to be left out of a group, those struggling with social anxiety know that it can feel just as excruciating to feel lonely within a group.

With these complications, addressing isolation can not be resolved simply with traditional cognitive behavioral therapy (CBT). I once attended a ComB training session where we filled out a worksheet of triggers. It was clear to me that if isolation or loneliness is a trigger for picking or pulling, a behavioral solution won’t be able to fully address these dynamics. A solution as simple and supportive as “spend time with friends” can’t work if the social skills necessary to fit in are not in place.

Dialectical and behavioral therapy (DBT) can serve as an adjunct to CBT to address isolation. The DBT protocol includes social skills, awareness of emotions, and conflict resolution skills. Nancy Keuthen et. al.’s 2011 study provides evidence that the addition of DBT to ComB helps toward positive and sustained outcomes in both hair pulling and emotional regulation than with the traditional ComB protocol alone.

From my psychodynamic perspective, the therapeutic relationship itself is the best vehicle for working through the pain of isolation, whatever the cause. The therapy dyad is a great place to learn the emotional regulation and assertiveness skills necessary to resolve conflicts, grieve losses and set boundaries. In turn, these skills can translate into the ability to form healthy relationships with others.

For example, in her 3 month post-therapy interview, Anna described the work we did together to address the isolation she felt as she navigated being as a mother of two young children. She had learned to cope with negative feelings like sadness and anger by herself, as she explained, “I had a happy childhood and felt emotionally safe in my house, but there were sort of like edges beyond which you couldn’t go, like rage. So (in therapy) we talked about how I do have those emotions and that it’s okay to have those ones that feel kind of scary.”

Anna had been feeling distant from her husband and realized that she felt resentful about the responsibilities she felt as the main caretaker of the children. Once she was able to accept that having those feelings didn’t make her a bad mom, she was able to share her overwhelm with her husband.

“I was seeing (Stacy) when we went on a big trip with both sets of family, and she helped me to communicate with my husband about what I needed from him, which was really helpful and I wasn’t harboring resentments. Therapy opened up a lot of communication for us.”

The process of learning to drop the “good girl” or “good boy” persona that has been so helpful in the past is painful and difficult, as fears of conflict run deep. The ability to tolerate and express one’s most painful emotions can cut through the veil of isolation. In time, it is possible to form deeper and more satisfying connections. These connections, in turn, can relieve the feelings of isolation that lead to picking and pulling.

References:

Keuthen, N., Rothbaum, B., Falkenstein, N. et al. (2011). DBT-enhanced habit reversal treatment for trichotillomania: 3- and 6-month follow up results. Depression and Anxiety, 28 (4), 310-313.