One way to conceptualize BFRBs is as overgrooming behaviors, or “grooming gone wild.” In a chapter of that name, Natterson-Horowitz and Browers (2013) discuss the research into similarly body-focused repetitive behaviors such as over-licking, barbering and feather-plucking among domesticated or captive animals. A common finding across species is that these behaviors are triggered by isolation, frustration, boredom and the stress of being trapped in too small of a space (Natterson-Horowitz & Browers, 2013). Encouragingly, research also shows that improvement of the conditions of an over-grooming animal’s environment can lead to a reduction or elimination of the behaviors.

In fact, the benefits of addressing the isolation of an over-grooming animal by providing more social contact can be profound. Incredibly, benefits of this contact can be seen across species. Natterson-Horowitz and Browers (2013) describe a case in which a horse’s flank-biting behavior declined when a chicken was added to his pen, as his triggering experience of isolation decreased.

For similar reasons, group therapy is an evidence-based modality for treatment of many behaviors and diagnoses (Blackmore, et al., 2009). As with animals, common triggers for engagement in BFRBs in humans include boredom, anxiety, frustration and tension (Roberts, O’Connor & Belanger, 2013). Group therapy is uniquely suited to address these issues.

Group therapy can provide access to a ‘healing herd’ for people who struggle with picking and pullng behaviors. Group therapy directly addresses the isolation that is often both a precipitant and consequence of reliance on BFRBs. My groups provide a supportive environment in which members can share some of the details of their engagement in BFRBs. This sharing allows them to develop self-compassion, an important ingredient in the healing process. Brene Brown (2012) explains, “Self-compassion is key because when we’re able to be gentle with ourselves in the midst of shame, we’re more likely to reach out, connect, and experience empathy.” Self-compassion is the best antidote to the BFRB engagement/shame/intensified BFRB engagement cycle that frequently multiplies stress for pickers and pullers.

One goal of psychodynamic group therapy is for members to talk about the feelings that underlie problematic behaviors. With many clients, and with pickers and pullers in particular, frustration and anger are some of the feelings that are most likely to have been suppressed. The expression of some of those ‘bad’ feelings to supportive group members can be transformative.

I have led a number of groups for pre-teens and teens who pick and pull. This modality can be more effective than individual therapy at helping adolescents shake off the shame that has coated their secret engagement in BFRBs. In my experience, this relief, along with the opportunity to vent frustrations and connect with peers, usually leads to a reduction in BFRB symptoms.

I run three weekly general process groups for adults, many of whom are pickers and pullers. This week, in one of my adult groups, I was reminded of how perfect this modality for helping my clients put their behavioral symptoms into words. P has been with me in group and individual therapy with me for several years. Through the years, I have watched P gain confidence, form healthier relationships, and re-engage in art. Still, she struggles with recognizing some of her unpleasant feelings and putting them into words. Over the years, I have gotten to know P’s ‘go-to’ non-verbal communication when she is distressed—she presses on her thumb, soothing herself while withdrawing from the group.

At times, I have tried to comment directly on this behavior, to no effect. P has always given me the clear message that she doesn’t want to talk about it. In this week’s group, I noticed that whenever P was talking, she wasn’t pressing on her finger. The longer she went without giving her input into a conversation, the more she would engage in the behavior. I engaged the group in a question about what they leave out of the room in their ‘niceness,’ and by the end of the group P. was talking more and thumb-pressing less.

In our individual session later in the week, I mentioned that I want to write about what I noticed about her behavior in group, and asked her permission to include this vignette in my blog. She agreed. She was interested in my observations, and told me that she hadn’t noticed that she had been using her “thumb soothing” technique this week. She did, however, remember pressing sharply on her thumb a lot during last week’s group. She told me she has been having trouble expressing her irritation at another group member, and had “hated” group that week. We agreed to continue working in bringing her angry feelings into the group room in words.

Animal behaviorist Robin Dunbar (1996) hypothesizes that when primates evolved into humans, the development of language replaced grooming behaviors in many of their social functions: communication, peace-making, and the establishment of hierarchy.

In my experience, the power of group therapy when applied to over-grooming behaviors lends credence to Dunbar’s hypothesis. Unconsciously, BFRBs can serve as communications of unexpressed needs and feelings as well as unspoken social and familial dynamics. In P’s case, verbal expression is beginning to replace body-focused behaviors, as her ability to put words to her thoughts and feelings grows through her participation in the group.

References:

Blackmore, C., Beecroft C., Parry, G., Booth, A., Tantam, D., Chambers, E., ... Saxon, D. (2009). A systematic review of the efficacy and clinical effectiveness of group analysis and analytic/psychodynamic group psychotherapy. Sheffield, UK: University of Sheffield.

Brown, Brene. (2012). Daring greatly: How the courage to be vulnerable transforms the way we live, love, parent, and lead. NY, NY: Penguin Group.

Dunbar, R. (1996). Grooming, gossip and the development of language. London: Faber & Faber.

Natterson-Horowitz, B., & Bowers, K. (2013). Zoobiquity: The astonishing connection between human and animal health. New York, NY: Vintage.

Roberts, S., O’Connor, K, & Belanger, C. (2013). Emotion regulation and other psychological models for body-focused repetitive behaviors. Clinical Psychology Review, 33 (pp. 745-762).