Setting Goals in Therapy: It's Not All or Nothing

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.

Why Begin with a Safety Phase?

Many skin-pickers and hair-pullers come to therapy in desperation, with one goal: help me stop doing this!

While some therapists might jump right in to behavioral strategies to get rid of unwanted behaviors, I choose instead to slow down the process.

Why?

Because as a therapist, one of my primary duties to my clients is to do no harm. Trying to get rid of a behavior before understanding the role it serves can do harm by setting clients up for failure and relapse and by putting a bandaid on the symptom of a deeper issue while ignoring the issue itself. Cross-addictions are a real risk if recovery happens too quickly, as people turn to other harmful behaviors like overeating or alcohol abuse to compensate for the loss of the picking or pulling behavior.

Wait a second, how can getting rid of a behavior that causes negative consequences like damage to one’s appearance, medical complications and shame be considered a loss?

One of my clients came up with a metaphor to describe this paradox: she calls hair-pulling her blanket with thorns. This phrase, blanket with thorns, captures the function of hair-pulling—to soothe the central nervous system—as well as the pain of it. When I think about it in that way, it becomes clear that as a therapist I’m not interested in immediately pulling off someone’s blanket! Ouch!

So, instead of moving into action, I begin therapy with each individual with a safety phase. In this phase, we find a way to respect the role hair-pulling or skin-picking has had in helping each person cope with the ups and downs of their lives.

I explain that our patience will pay off. Once we understand the many different feelings picking and pulling have been helping us to manage, from numbness to sadness to dissociation to anger to grief, we might not be so angry at ourselves for picking and pulling. Now, in therapy, we have a place to express our feelings, and we can be nicer to ourselves about how hard this has all been and we can cry and yell and do whatever we need to do to feel our feelings.

As feelings are bottled up less and less the need to need to pick and pull also lessens. It doesn’t go away, but the urges just aren’t so terrible. It becomes possible to start bringing new soothing behaviors into the toolbox. A safety phase can create more room to let go of ingrained behaviors and to reach for healthier possibilities.

To arrive at a place of receptivity to behavioral change, several goals must be met in the safety phase: a full psycho-social assessment, development of self-compassion, the creation of reasonable goals, and building a foundation of trust between therapist and client.

A comprehensive assessment begins with an understanding of the various stress factors and the state of current relationships and how these may intersect with the intensity of picking and pulling behaviors. At some point, the assessment must include a dive back into the circumstances that led to the initial development of the body-focused behavior. Was there a loss that led to the need to reach for extra comfort? A traumatic incident that triggered a new coping strategy? Underlying depression or anxiety that needed to be soothed? Perfectionism about grades or looks?

This assessment process serves as a building block for self-compassion. Understanding the needs that underlie picking and pulling behaviors helps to counter the self-hate and disgust that accompany the behaviors. Education about the physiological sensitivities common to those who pick and pull and the role of picking and pulling as coping mechanisms helps to disarm the shame that feeds the pick or pull/shame/pick or pull cycle.

Realistic goal-setting involves moderation rather than perfection. Some people can let go of hair pulling or skin picking for good, but new stressors can tend to bring old behaviors to the fore. Goal-focused work that tracks behaviors can feed the perfectionism that is part of the problem, while the idea of accepting some level of picking or pulling while reducing intensity and negative consequences can lead in a healthier new direction.

All of these steps, within the first month or two of therapy, set the foundation for a trusting relationship to form with the therapist. This trust is a key factor in the success of therapy of any modality.

Next, keep your eyes open in February for part 2 of 3: The Exploration Phase: Building a Toolbox of Emotional Regulation Skills.

’