Being a "Good Girl" or "Good Boy": Perfectionism and Body-Focused Repetitive Behaviors

Researchers have noticed that people who pick their skin and pull out their hair tend to be perfectionists and over-achievers . There is also clear evidence that picking and pulling arise from difficulties with emotional regulation, like having a harder time calming down when upset and lacking communication skills.

I have not yet seen a satisfying explanation of the commotion between how perfectionism, emotional regulation and BFRBs intersect. In my work of more than a decade with pickers and pullers, I have come to understand something about this intersection: the “good girl” or “good boy” has learned that the so-called negative feelings such as anger and sadness are not welcomed in the home.

In trying to please parents or trying to cause as little stress as possible in an otherwise stressful time, perfectionism can develop as a defensive maneuver. Emotions that are seen as undesirable aren’t fully felt or expressed; rather, they are suppressed and a false, happier front takes the stage. Pent-up energy is channeled toward achievements that earn praise and keep up the appearance that everything is OK.

The perfectionism defense is often very successful at keeping unwanted emotions at bay, and achieving successes and getting kudos along the way! The only problem is that emotions don’t just disappear. Emotional energy has to come out somewhere. Pulling out a hair or picking a pimple can be just the thing to release built-up tension bit by bit.

The problem becomes a cycle, then, because picking and pulling cause damage too, that now must be covered up, as the frustration with having caused imperfections is hard to tolerate and adds more fuel to the inner tension.

So, now that we understand a bit more about this dynamic, let’s see how psychodynamic therapy might play a role in untangling emotions, perfectionism, and picking and pulling behaviors. In particular, by taking the time to establish safety before trying to change picking and pulling behaviors, it makes room for a relational dive into the feelings that have been tucked away. These feelings are too overwhelming to experience alone, but with a trusted they can be felt, processed, and released.

Anna, a 30 year old mother of 2 small children explained in her 3 month post-therapy interview how our work on emotional regulation helped her drop her lifelong shield of perfection, “The perfectionism was part of the problem. With Stacy, I figured out that I didn’t have to have perfectly clear, wonderful skin that I never picked in order to be happy and to feel like I was in control of my life and of my picking.”

The process of learning to drop the “good girl” or “good boy” persona that has been so helpful in the past is often painful and difficult. The journey is worth it, as the ability to tolerate and express one’s most painful emotions can cut through the veil of isolation. Deeper connections can bring the very comfort and emotional support that can relieve pressure on the need to pick and pull.

Isolation as a Trigger for BFRBS: It's Complicated

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.