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

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.

References:

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.

Soon after my clients begin treatment for picking and/or pulling, I tend to bring up the topic of anger. This is not a topic most of my clients are comfortable discussing.

Over the years, I’ve noticed that many pickers and pullers bottle up their anger rather than expressing it, and that this internalized anger often becomes a trigger for their body-focused repetitive behaviors (BFRBs). Suppressing anger can be a useful coping mechanism, as parents and others may react negatively to its expression, and reversing this ingrained response often feels like a dangerous and overwhelming proposition.

In 2016, Curley, Tung & Keuthen published a study titled “Trait Anger, Anger Expression, and Anger Control in Trichotillomania: Evidence for the Emotion Regulation Model.” The study focuses on the connection between the internalization of anger and BFRBs.

Their conclusions validate my focus on helping my clients to express their anger. "This study demonstrates that there is a clear relationship between TTM [trichotillomania] and anger directed inward. Individuals with TTM have both a tendency to suppress anger and difficulty controlling and reducing this inward expression of anger, suggesting that hair pullers may have trouble regulating their anger" (p. 79).

One way I can help my clients reduce the stress in their "stress cups," (see May's blog below) and take pressure off the need to pick or pull is to help them regulate their anger effectively instead of turning it inward. This process involves several steps:

1. Identify angry feelings and locate them in the body.

Many who struggle with BFRBs have turned off internal emotional sensors, especially those related to anger, in order to cope with their environments. When I am with a client, I often notice cues that they are angry or irritated, either with me or with someone else. These cues might include using a curse word or slapping a knee while talking. In these moments, I can help them check in with their bodies to see if there might be some tightness or other sensation somewhere inside. I can help to name this sensation as anger and take some of its power away. As we go along, we can begin connect what we were talking about in our session with that uneasy feeling.

2. Understand how suppressing feelings has worked as a coping mechanism.

Anger can feel very scary. Many people have valid fears about what might happen if they turn their aggressive impulses toward others. We can begin to understand the ways anger at others is turned toward the self through negative self-talk and engagment in BFRBs. Once the reliance on self-defeating behaviors is understood, it is easier to consider that an outward expression of anger might be safe in a new, healthier environment.

3. Develop emotional regulation skills.

I encourage clients to express their anger or frustration at me when it arises. By encouraging the expression of anger in the moment, I can help them them to begin to calm themselves down. Neurobiological research explains how a therapist's calm and centered presence can help clients begin to relax their central nervous systems. My response to a client's dissatisfaction with me is to validate and invite negative feedback. I explain that their expression of anger helps me to get to know them and can help me understand how to be a better therapist. In order to help them to bring these regulation strategies into their daily lives, I often share the metaphor of an anger pendulum. I explain that if we’ve been repressing anger, we may be clumsy when we try to express it, sometimes blowing up or saying hurtful things, moving from passive to aggressive. Luckily, as we get more comfortable with our angry feelings, we can begin to communicate them more effectively and move into the middle ground between passivity and aggression, assertiveness. Additionally, I often encourage physical activity as an emotional release.

It takes courage to get in touch with feelings that have we have repressed like grief and anger. The good news is that our bodies have all of the information we need to cue in to these unwanted feelings and begin to befriend them. A therapist's presence can make it easier to relax while discussing painful feelings and begin to soften the pain we have been trying to avoid. Once we are comfortable with expressing our anger in healthy, productive ways, we may notice less pressure on the stress cup that contributes to engagement in picking and pulling.

References:

Curley, E., Tung, E. & Keuthen, N. (2016). Trait anger, anger expression, and anger control in trichotillomania: Evidence for the emotion regulation model. Journal of Obsessive-Compulsive and Related Disorders, 9, 77-81.

Family Therapy for Adolescents with Body-Focused Repetitive Behaviors

Internalized Anger as a Trigger for Picking and Pulling